Assessment discussion wk 1

1

The History and
Interviewing Process

CHAPTER

1 
This chapter discusses the development of relationships

with patients and the building of the histories or health-
care narratives. We write of it as “building” a history rather
than “taking” one because you and your patient are involved
in a joint effort, a partnership, which should have, among
other outcomes, a history that truly reflects the patient’s
perspectives and unique status (Haidet, 2010; Haidet and
Paterniti, 2003). The chapter discusses the context of the
relationship in emotional, physical, and ethical terms and
offers suggestions in verbal and nonverbal behavior that you
may adapt to your individual comfort and style. Finally, we
offer widely accepted, time-tested approaches to the structure
of a history with adaptations suggested for age, children,
adolescents, pregnant patients, older adults, and patients
with disabilities. The history is vital to the appropriate
interpretation of the physical examination.

Developing a Relationship With the Patient
Our purpose is to offer instruction in learning about the
well and the sick as they seek care. History and physical
examination are at the heart of this effort. It is not easy to
get the sense of another person or to fully appreciate
someone else’s orientation in the world. You and the patient
may seem to have a similar experience but may in all
likelihood interpret it differently (see Clinical Pearl,
“Unique,” Originally Derived From Latin “Unus,” Meaning
“One”). On the other hand, you and your patient may come
from very different backgrounds without any shared experi-
ences. If you are to prevent misinterpretations and misper-
ceptions, you must make every effort to sense the world
of the individual patient as that patient senses it. (See
Chapter 2 for additional discussion.)

The first meeting with the patient sets the tone for a
successful partnership as you inform the patient that you
really want to know all that is needed and that you will be
open, flexible, and eager to deal with questions and explana-
tions. You can also explain the boundaries of your practice
and the degree of your availability in any situation. Trust
evolves from honesty and candor.

A primary objective is to discover the details about a
patient’s concern, explore expectations for the encounter,
and display genuine interest, curiosity, and partnership.
Identifying underlying worries, believing them, and trying
to address them optimizes your ability to be of help. You
need to understand what is expected of you. If successful,
the unique and intimate nature of the interview and physical
examination will be reinforced. You will savor frequent
tender moments with patients when you recognize that
your efforts are going well and that trust is there. We want
to help ensure those moments occur.

CLINICAL PEARL

“Unique,” Originally Derived From Latin “Unus,”
Meaning “One”
We use “unique” in that sense of being the only one. Each of us is
unique, incomparably different from anyone in the past, present, or
future. No relationship, then, has an exact counterpart. Each moment
is unique, different from the time before with the same patient.

From Merriam-Webster’s Learner’s Dictionary, 2016.

CLINICAL PEARL

The Patient Relationship
You will, in the course of your career, have numerous relationships
with patients. Never forget that each time they are having an experience
with you, it is important to them.

Much has been written about technology replacing the
history and physical examination in some part, but personal-
ized care of patients goes far beyond the merely technical.
Appropriate care satisfies a need that can be fully met only
by a human touch, intimate conversation, and the “laying
on of hands.” Personal interactions and physical examination
play an integral role in developing a meaningful and
therapeutic relationships with patients (Kugler and Verghese,
2010).

This actual realization of relationships with patients,
particularly when illness compounds vulnerability, cannot
be replaced (see Clinical Pearl, “The Patient Relationship”).

Because cost containment is also essential, the well-
performed history and physical examination can justify the
appropriate and cost-effective use of technological resources.
This underscores the need for judgment and the use of
resources in a balance appropriate for the individual patient.

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ss them. You have to be aware of your cultural beliefs, faith,
and conscience so that they do not inappropriately intrude
as you discuss with patients a variety of issues. That means
knowing yourself (Curlin et al, 2007; Gold, 2010; see also
Chapter 2).

You react differently to different people. Why? How?
Do you want to be liked too much? Does thinking about
how you are doing get in the way of your effort? Why does
a patient make you angry? Is there some frustration in
your life? Which of your prejudices may influence your
response to a patient? Discuss and reflect on such questions
with others you trust rather than make this a lonely,
introspective effort. You will better control possible barriers
to a successful outcome.

Effective Communication
Establishing a positive patient relationship depends on
communication built on courtesy, comfort, connection, and
confirmation (Box 1.2).

Be courteous; ensure comfort, both physical and emo-
tional; be sure that you have connected with the patient with
trust and candor; and confirm that all that has happened
during the interaction is clearly understood and your
patient is able to articulate the agreed-on plan. That is
communication.

Seeking Connection. Examine your habits and modify them
when necessary so that you are not a barrier to effective
communication. Stiff formality may inhibit the patient; a
too-casual attitude may fail to instill confidence. Do not be
careless with words—what you think is innocuous may
seem vitally important to a patient who may be anxious
and searching for meaning in everything you say. Consider
intellectual and emotional constraints related to how you
ask questions and offer information, how fast you talk, and
how often you punctuate speech with “uh-huh” and “you
know.” The interaction requires the active encouragement
of patient participation with questions and responses
addressed to social and emotional issues as much as the
physical nature of health problems.

At the start, greet the patient. Welcome others and ask
how they are connected to the patient. Begin by asking
open-ended questions (“How have you been feeling since
we last met?” “What are your expectations in coming here
today?” “What would you like to discuss?” “What do you
want to make sure we cover in today’s visit?”). Resist the
urge to interrupt in the beginning. You will be amazed
how many times a complete history is provided without
prompting. Later, as information accumulates, you will
need to be more specific. However, early on, it is entirely
appropriate to check the patient’s agenda and concerns and
let the information flow. It is important not to interrupt
the patient at the start of the interview and to ask whether
there is “anything else” a few times to be sure the patient’s
primary concerns are identified early in the visit. Thus,
you and the patient can collaboratively set the current visit’s
agenda.

At a first meeting, you are in a position of strength and
your patients are vulnerable. You may not have similar per-
spectives but you need to understand the patient’s if you are
to establish a meaningful partnership. This partnership has
been conceptualized as patient-centered care, identified by
the Institute of Medicine (IOM) as an important element of
high-quality care. The IOM report defined patient-centered
care as “respecting and responding to patients’ wants, needs
and preferences, so that they can make choices in their care
that best fit their individual circumstances” (IOM, 2001).
Box 1.1 identifies questions that represent a patient-centered
approach in building a history. Your own beliefs, attitudes,
and values cannot be discarded, but you do have to discipline

BoX 1.1 Patient-Centered Questions

The following questions represent a patient-centered approach in
building a history.
• How would you like to be addressed?
• How are you feeling today?
• What would you like for us to do today?
• What do you think is causing your symptoms?
• What is your understanding of your diagnosis? Its importance? Its

need for management?
• How do you feel about your illness? Frightened? Threatened?

Angry? As a wage earner? As a family member? (Be sure, however,
to allow a response without putting words in the patient’s mouth.)

• Do you believe treatment will help?
• How are you coping with your illness? Crying? Drinking more?

Tranquilizers? Talking more? Less? Changing lifestyles?
• Do you want to know all the details about your diagnosis and its

effect on your future?
• How important to you is “doing everything possible”?
• How important to you is “quality of life”?
• Have you prepared advance directives?
• Do you have people you can talk with about your illness? Where

do you get your strength?
• Is there anyone else we should contact about your illness or

hospitalization? Family members? Friends? Employer? Religious
advisor? Attorney?

• Do you want or expect emotional support from the healthcare
team?

• Are you troubled by financial questions about your medical care?
Insurance coverage? Tests or treatment you may not be able to
afford? Timing of payments required from you?

• If you have had previous hospitalizations, does it bother you to be
seen by teams of physicians, nurses, and students on rounds?

• How private a person are you?
• Are you concerned about the confidentiality of your medical records?
• Would you prefer to talk to an older/younger, male/female healthcare

provider?
• Are there medical matters you do not wish to have disclosed to

others?
We suggest that use of these questions should be determined by

the particular situation. For example, talking about a living will might
alarm a patient seeking a routine checkup but may relieve a patient
hospitalized with a life-threatening disease. Cognitive impairment,
anxiety, depression, fear, or related feelings as well as racial, gender,
ethnic, or other differences should modify your approach.

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CHAPTER 1 The History and Interviewing Process 3

Confidentiality, which is important in all aspects of care,
is another essential element. The patient should provide
the information. It is important to identify everyone in the
room to be sure the patient is comfortable and wants others
to participate in the visit. You may want to ask the parent,
spouse, or other person to step out of the room so you can
have a confidential discussion with the patient. If language

Having clear and agreed-upon goals for each interaction
leads to successful communication. You must be a skilled
listener and observer with a polished sense of timing and
a kind of repose that is at once alert and reassuring. Your
nonverbal behavior complements your listening. Your face
need not be a mask. You can be expressive and nod in
agreement, but it is better to avoid the extremes of reaction
(e.g., startle, surprise, or grimacing). Eye contact should
be assured and comfortable, and your body language should
show that you are really in the room, open to and engaged
with the patient. You should be comfortably seated close
to the patient and, if using an electronic medical record,
so you and the patient can both visualize the screen. Do
not stand and do not reach for the doorknob (see Clinical
Pearl, “Professional Dress and Grooming”).

Remember that patients also communicate nonverbally,
and understanding this is advantageous to both you and
the patient (Henry et al, 2012).

BoX 1.2 Communication

Courtesy, Comfort, Connection, Confirmation
Courtesy
• Knock before entering a room.
• Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is

all right to shake hands.
• Meet and acknowledge others in the room and establish their roles

and degree of participation.
• Learn their names.
• Ensure confidentiality.
• Be in the room, sitting, with no effort to reach too soon for the

doorknob.
• If taking notes, take notes sparingly; note key words as reminders

but do not let note-taking distract from your observing and
listening.

• If typing in the electronic medical record, type briefly and maintain
eye contact with patient, if possible.

• Respect the need for modesty.
• Allow the patient time to be dressed and comfortably settled after

the examination. Follow-up discussion with the patient still “on the
table” is often discomfiting.

Comfort
• Ensure physical comfort for all, including yourself.
• Try to have a minimum of furniture separating you and the

patient.
• Maintain privacy, using available curtains and shades.
• Ensure a comfortable room temperature or provide a blanket—a

cold room will make a patient want to cover up.
• Ensure good lighting.
• Ensure necessary quiet. Turn off the television set.
• Try not to overtire the patient. It is not always necessary to do it all

at one visit.

Connection
• Look at the patient; maintain good eye contact if cultural practices

allow.

• Watch your language. Avoid professional jargon. Do not patronize
with what you say.

• Do not dominate the discussion. Listen alertly. Let the patient order
priorities if several issues are raised.

• Do not accept a previous diagnosis as a chief concern. Do not too
readily follow a predetermined path.

• Find out whether the patient has turned from other healthcare providers
to come to you.

• Take the history and conduct the physical examination before you
look at previous studies or tests. Consider first what the patient has
to say.

• Avoid leading or direct questions at first. Open-ended questions are
better for starters. Let specifics evolve from these.

• Avoid being judgmental.
• Respect silence. Pauses can be productive.
• Be flexible. Rigidity limits the potential of an interview.
• Assess the patient’s potential as a partner.
• Seek clues to problems from the patient’s verbal behaviors and body

language (e.g., talking too fast or too little).
• Look for the hidden concerns underlying chief concerns.
• Never trivialize any finding or clue.
• Problems can have multiple causes. Do not leap to one cause too

quickly.
• Define any concern completely: Where? How severe? How long? In

what context? What soothes or aggravates the problem?

Confirmation
• Ask the patient to summarize the discussion. There should be clear

understanding and uncertainty should be eased.
• Allow the possibility of more discussion with another open-ended

question: “Anything else you want to bring up?”
• If there is a question that you cannot immediately answer, say so.

Be sure to follow up later if at all possible.
• If you seem to have made a mistake, make every effort to repair it.

Candor is important for development of a trusting partnership. Most
patients respect it.

CLINICAL PEARL

Professional Dress and Grooming
Appropriate dress and grooming go a long way toward establishing a
first good impression with the patient. Although clean fingernails, modest
clothing, and neat hair are imperative, you need not be formal to be
neat. You can easily avoid extremes so that appearance does not
become an obstacle in the patient’s response to care.

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ss When asking how often something happened, allow the
patient to define “often,” rather than asking, “It didn’t
happen too often, did it?”
Sometimes the patient does not quite understand what

you are asking and says so. Recognize the need when it is
appropriate to:
• Facilitate—encourage your patient to say more, either

with your words or with a silence that the patient may
break when given the opportunity for reflection.

• Reflect—repeat what you have heard to encourage more
detail.

• Clarify—ask, “What do you mean?”
• Empathize—show your understanding and acceptance.

Do not hesitate to say “I understand,” or “I’m sorry” if
the moment calls for it.

• Confront—do not hesitate to discuss a patient’s disturbing
behavior.

• Interpret—repeat what you have heard to confirm the
patient’s meaning.
What you ask is complemented by how you ask it. Take

the following actions, if necessary, to clarify the patient’s
point of view:
• Ask what the patient thinks and feels about an issue.
• Make sure you know what the chief concern is.
• Ask about the patient’s life situation, so that nothing

seemingly extraneous to the chief concern and present
illness has gone unnoticed.

• Suggest at appropriate times that you have the “feeling”
that the patient could say more or that things may not
be as well as they are reported.

• Suggest at appropriate times that it is all right to be
angry, sad, or nervous, and it is all right to talk about it.

• Make sure that the patient’s expectations in the visit are
met and that there are no further questions.
Make sure your questions are clearly understood. Define

words when necessary and choose them carefully. Avoid
technical terms if possible. Adapt your language when
necessary to the patient’s education level. Ask the patient
to stop you if he or she does not understand what you are
talking about. Similarly, do the same if you do not grasp
the patient’s meaning. For example, a patient may report
that he had “low blood” (anemia), “high blood” (hyperten-
sion), “bad blood” (syphilis), and “thin blood” (he was taking
anticoagulants). It can take a bit of exploring to sort it all
out. Do not assume every question needs a complex and
technical answer. Avoid medical jargon with all patients,
even those who are in the healthcare field.

Moments of Tension: Potential Barriers
to Communication

Curiosity About You. Patients will sometimes ask about
you. Although you are not the point, you may be comfortable
revealing some relevant aspects of your experience (“I have
trouble remembering to take medicines too” or “I remember
when my children had tantrums”). A direct answer will
usually do. Often, simply informing your patients that you
have experienced similar life events (e.g., illness, pregnancy,

is a barrier, a professional interpreter, rather than a family
member, should be used (Fig. 1.1).

Gentle guidance and polite redirection are sometimes
necessary to keep the visit focused and moving forward
(e.g., “Now let’s also talk about …” or “I’m sorry to interrupt,
but let me make sure I understand …”). Be prepared with
questions you think are important to address based on the
patient’s history and main concerns. If the patient touches
on something that does not seem immediately relevant to
your purposes (e.g., introducing a possible problem not
previously mentioned), be flexible enough to clarify at least
the nature of the concern. Some apparent irrelevancies
may contain clues to the care-seeking behaviors or concerns
that may be hidden beneath the primary concern and may
greatly help in understanding the patient’s illness perspec-
tive. The patient’s body language will also suggest the
intensity of an underlying feeling. Although too many
digressions can lead to misspent time, paying attention
may save a lot of time later, and information learned may
be important to the future plan of care.

Enhancing Patient Responses. Carefully phrased questions
can lead to more accurate responses. Ask one question
at a time, avoiding a barrage that discourages the patient
from being complete or that limits answers to a simple yes
or no:
• The open-ended question gives the patient discretion

about the extent of an answer: “Tell me about …” “And
then what happened?” “What are your feelings about
this?” “What else do you need to talk about?”

• The direct question seeks specific information: “How
long ago did that happen?” “Where does it hurt?” “Please
put a finger where it hurts.” “How many pills did you
take each time?” and “How many times a day did you
take them?”

• The leading question is the most risky because it may
limit the information provided to what the patient thinks
you want to know: “It seems to me that this bothered
you a lot. Is that true?” “That wasn’t very difficult to do,
was it?” “That’s a horrible-tasting medicine, isn’t it?”

FIg. 1.1 Interviewing a patient with the help of an interpreter. Someone
other than a family member should act as interpreter to bridge the language
difference between the healthcare provider and the patient.

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CHAPTER 1 The History and Interviewing Process 5

Crying and Compassionate Moments. People will cry.
Let the emotion proceed at the patient’s pace. Resume your
questioning only when the patient is ready. If you suspect
a patient is holding back, give permission. Offer a tissue
or simply say, “It seems like you’re feeling sad. It’s OK to
cry.” Name the emotion. Be direct about such a tender
circumstance, but gently, not too aggressively or insistently.
Do not hesitate to say that you feel for the patient, that you
are sorry for something that happened, and that you know
it was painful. At times, the touch of a hand or even a hug
is in order. Sometimes, a concern—a difficult family relation-
ship, for example—must be confronted. You may have to
check an assumption and hope that you have guessed
correctly in bringing the patient’s feelings to the surface.
If uncertain, ask without presupposing what the response
might be.

Physical and Emotional Intimacy. It is not easy to be
intimate with the emotions and the bodies of others. Cultural
norms and behaviors are at once protective of and barriers
to trusting relationships. The patient is in a dependent
status as well. You can acknowledge this while explaining
clearly and without apology what you must do for the
patient’s benefit. Of course, respect modesty, using covers
appropriately without hampering a complete examination.
Be careful about the ways in which you use words or frame
questions. You cannot be sure of the degree to which a
given patient has been “desensitized” to the issues of
intimacy. However, respect for modesty carried too far, such
as skipping examination of the genitals, can be a trap
delaying or barring access to much needed information.
You can keep the necessary from becoming too big an
issue by being calm and asking questions with professional
poise.

Seduction. Some patients can be excessively flattering
and manipulative and even seductive. Their illness and
insecurity beg for extra-special attention. Do not be taken
in by this. There are limits to warmth and cordiality.
Certainly not all touch is sexually motivated; a heartfelt
hug is sometimes just right. Nevertheless, beware of that
trap. Avert it courteously and firmly, delivering the immedi-
ate message that the relationship is and will remain profes-
sional. It takes skill to do this while maintaining the patient’s
dignity, but there is no room for sexual misconduct in the
relationship, and there can be no tolerance for exploitation
of the patient in this regard.

Anger. Sometimes the angriest patients (or persons with
them) are the ones who may need you the most. Of course,
it can be intimidating. Confront it. It is all right to say, “It
seems like you’re angry. Please tell me why. I want to hear.”
Speak softly and try not to argue the point. You may not
know if or why you made someone angry. Most often, you
have done nothing wrong, and the patient’s emotion is
unrelated to you or the visit. Still, the stress of time, heavy
workload, and the tension of caring for the acutely—even
terminally—ill can generate your own impatience and
potential for anger. Avoid being defensive, but acknowledge
the problem. Only when appropriate, apologize and ask

and childbirth) can help alleviate fears and, with further
exploration, can help in the identification of the patient’s
concerns. The message that you are a “real” person can
lead to a trust-enhancing or even therapeutic exchange. At
the same time, it is wise to exercise caution and remain
professional in what and how much you disclose (Lussier
and Richard, 2007).

Anxiety. Anxiety has multiple sources, such as an
impending procedure or anticipated diagnosis. Some
disorders will be more likely to cause an intense response,
such as those associated with crushing chest pain or dif-
ficulty in breathing; with other disorders, just seeing a
healthcare professional can cause anxiety. You can help by
avoiding an overload of information, pacing the conversation,
and presenting a calm demeanor.

Silence. Sometimes intimidated by silence, many health-
care providers feel the urge to break it. Be patient. Do not
force the conversation. You may have to move the moment
along with an open-ended question (“What seems to worry
you?”) or a mild nudge (“And after that?”). Remember, though,
that silence allows the patient a moment of reflection or
time to summon courage. Some issues can be so painful
and sensitive that silence becomes necessary and should
be allowed. Most people will talk when they are ready. The
patient’s demeanor, use of hands, possible teary eyes, and
facial expressions will help you interpret the moment. Silence
may also be cultural: for example, some cultural groups take
their time, ponder their responses to questions, and answer
when they feel ready. Do not push too hard. Be comfortable
with silence but give it reasonable bounds.

Depression. Being sick or thinking that you are sick
can be enough to provoke situational depression. Indeed,
serious or chronic, unrelenting illness or taking certain
prescription medications (e.g., steroids) is often accompanied
by depression. A sense of sluggishness in the daily experi-
ence; disturbances in sleeping, eating, and social contact;
and feelings of loss of self-worth can be clues. In addition
to screening for depression at ambulatory visits, pay atten-
tion. First ask, “When did you start feeling this way?” Then
ask, “How do you feel about it?” “Have you stopped enjoying
the things you like to do?” “Do you have trouble sleeping?”
“Have you had thoughts about hurting yourself?” “Are you
depressed?” A patient in this circumstance cannot be hurried
and certainly cannot be relieved by superficial assurance.
You need not worry about introducing the idea of suicide
(see Clinical Pearl, “Adolescent Suicide”). It has most often
been considered, if only briefly (see Chapter 7, Risk Factors
box, “Suicide”).

CLINICAL PEARL

Adolescent Suicide
Suicide is a major cause of mortality in the preteen and teen years,
more often in boys. If the thought of it occurs to you, you can be pretty
sure that it has to the patient too. You can mention it and thus give
permission to talk about it. You will not be suggesting anything new.
You may actually help prevent it.

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one of your prime concerns. You can do this only by
concentrating on the matter at hand, giving it for that
moment primacy in your life and putting aside both personal
and professional distractions.

Structure of the History
You build the history to establish a relationship with the
patient, so that you jointly discover the issues and problems
that need attention and priority. A widely accepted approach
is provided that can and should be modified to fit the
individual circumstance:
• First, the identifiers: name, date, time, age, gender

identity, race, source of information, and referral source
• Chief concern (CC)
• History of present illness or problem (HPI)
• Past medical history (PMH)
• Family history (FH)
• Personal and social history (SH)
• Review of systems (ROS)

The chief concern is a brief statement about why the
patient is seeking care. Direct quotes are helpful. It is
important, however, to go beyond the given reason and to
probe for underlying concerns that cause the patient to
seek care rather than just getting up and going to work. If
the patient has a sore throat, why is help sought? Is it the
pain and fever, or is it the concern caused by past experience
with a relative who developed rheumatic heart disease?
Many interviewers include the duration of the problem as
part of the chief concern.

Understanding the present illness or problem requires
a step-by-step evaluation of the circumstances that surround
the primary reason for the patient’s visit. The full history
goes beyond this to an exploration of the patient’s overall
health before the chief concern, including past medical
and surgical experiences. The spiritual, psychosocial, and
cultural contexts of the patient’s life are essential to an
understanding of these events. The patient’s family also

how to make things better. Explore the feelings. Often, you
can continue on a better footing after anger is vented. On
occasion, nothing will seem to help. It is then all right to
defer to another time or even to suggest a different profes-
sional (Thomas, 2003).

Afterward, do not hesitate to talk about the episode with
a trusted colleague. It helps. Discussing the incident later
may lend insight into behaviors and help prevent the
occurrence again. Better ways of responding can be explored.

Avoiding the Full Story. Patients may not always tell the
whole story or even the truth, either purposely or uncon-
sciously. Dementia, illness, alcoholism, sexual uncertainties,
intimate partner violence, and child abuse are among the
reasons. Do not push too hard when you think this is
happening. Allow the interview to go on and then come
back to a topic with gentle questioning. You might say, “I
think that you may be more concerned than you are saying”
or “I think you’re worried about what we might find out.”
Unless there is concern about the safety of the patient or
another individual, learning all that is necessary may not
come in one sitting. You may have to pursue the topic at
a later visit or perhaps with other members of the family
or friends or your professional associates.

Financial Considerations. The cost of care and the
resulting drain on resources (and the potential impact on
employment or insurance coverage) are often sources of
stress for the patient. Talk about them with candor and
accurate knowledge. Provide resources (social worker or
financial counselor). Otherwise, an appropriate care plan
acceptable to the patient cannot be devised or implemented.
Pressing circumstances and obligations may still present
barriers to appropriate care.

The Patient History
A first objective in building the history is to identify those
matters the patient defines as problems, the subtle as well
as the obvious. You need to establish a sense of the patient’s
reliability as an interpreter of events. Consider the potential
for intentional or unintentional suppression or underreport-
ing of certain experiences that may give context to a problem
that is at odds with your expectation. Constantly evaluate
the patient’s words and behavior. The history is built on
the patient’s perspective, not yours. Make modifications as
required for the patient’s age and his or her physical and
emotional disabilities.

Setting for the Interview
Regardless of the setting, make everyone as comfortable
as possible. Position yourself so that there are no bulky
desks, tables, computer screens, or other electronic equip-
ment between you and the patient (Fig. 1.2). If possible,
have a clock placed where you can see it without obviously
looking at your watch (preferably behind the patient’s chair).
Sit comfortably and at ease, maintaining eye contact and
a conversational tone of voice. Your manner can assure the
patient that you care and that relieving worry or pain is

FIg. 1.2 Interviewing a young adult. Note the absence of an intervening
desk or table.

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CHAPTER 1 The History and Interviewing Process 7

walk a fine line between permitting this leisure and meeting
the many time constraints you are sure to have. Fix your
attention on the patient, avoid interrupting as much as
possible, and do not ask the next question before you have
heard the complete answer to the prior one.

The patient’s responses may at times be unclear. Seek
certainty:
• “Of what you’ve told me, what concerns you the most?”
• “What do you want to make sure we pay attention to

today?”
• “Do you have any ideas about what we ought to do?”
• Or a leading question sometimes, “I think _________

worries you the most. Am I right? Shall we talk about
that first?”
As the interview proceeds, thoroughly explore each

positive response with the following questions:
• Where? Where are symptoms located, as precisely as

possible? If they seem to move, what is the range of
their movement? Where is the patient when the complaint
occurs—at work or play, active or resting?

• When? Everything happens in a chronologic sequence.
When did it begin? Does it come and go? If so, how
often and for how long? What time of day? What day
of the week?

• What? What does it mean to the patient? What is its
impact? What does it feel like? What is its quality and
intensity? Has it been bad enough to interrupt the flow
of the patient’s life, or has it been dealt with rather
casually? What else happened during this time that might
be related? What makes it feel better? Worse?

• How? The background of the symptom becomes impor-
tant in answering the “how” question. How did it come
about? Are other things going on at the same time, such
as work, play, mealtime, or sleep? Is there illness in the
family? Have there been similar episodes in the past?
If so, how was it treated or did it resolve without treat-
ment? Is there concern about similar symptoms in friends
or relatives? Are there spouse complaints or concerns?
How is the patient coping? Are there social supports?
Nothing ever happens in isolation.

• Why? Of course, the answer to “why” is the solution to
the problem. All other questions lead to this one.
Once you have understood the patient’s chief concern

and present problem and you have a sense of underlying
issues, you may go on to other segments of the history:
the family and past medical histories; emotional, spiritual,
and cultural concerns; and social and workplace accompani-
ments to the present concerns. Remember that nothing in
the patient’s experience is isolated. Aspects of the present
illness or problem require careful integration with the
medical and family history. The life of the patient is not
constructed according to your outline, with many factors
giving shape to the present illness and with any one chief
concern possibly involving more than one illness.

A visit should conclude with a review:
• Ask the patient to try to satisfy gaps in your

understanding.

requires attention—their health, past medical history, ill-
nesses, deaths, and the genetic, social, and environmental
influences. One question should underlie all of your inquiry:
Why is this happening to this particular patient at this
particular time? In other words, if many people are exposed
to a potential problem and only some of them become ill
after the exposure, what are the unique factors in this
individual that led to that outcome? Careful inquiry about
the personal and social experiences of the patient should
include work habits and the variety of relationships in the
family, school, and workplace. Finally, the ROS includes a
detailed inquiry of possible concerns in each of the body’s
systems, looking for complementary or seemingly unrelated
symptoms that may not have surfaced during the rest of
the history. Flexibility, the appreciation of subtlety, and the
opportunity for the patient to ask questions and to explore
feelings are explicit needs in the process.

Building the History
Introduce yourself to the patient and accompanying persons
if you have not already met, clearly stating your name and
your role. If you are a student, say so. Be certain that you
know the patient’s full name and that you pronounce it
correctly. Ask if you are not certain.

Address the patient properly (e.g., as Mr., Miss, Mrs.,
Ms., or the manner of address preferred by the patient) and
repeat the patient’s name at appropriate times. Avoid the
familiarity of using a first name when you do not expect
familiarity in return. Do not use a surrogate term for a
person’s name; for example, when the patient is a child,
do not address the parent as “Mother” or “Father.” It is
respectful and courteous to take the time to learn each name.

It is respectful, too, to look at the patient and not at
the electronic device that is usually close at hand. Use it if
you must, but position it so that it does not distract from
the patient. More and more the electronic device in the
examination room is being introduced into the patient-
provider dynamic for documentation as well as educational
purposes (e.g., demonstrating the findings on an imaging
study, showing the trend of a laboratory result over time,
or reviewing a website together). Unless you already know
the patient and know that there is urgency, proceed at a
reasonable pace, asking for the reason for the visit with the
intent of learning what their specific expectations of the
visit are. Listen, and do not be too directive. You will often
be surprised at how much of the story and details you will
hear without pushing. Let the patient share his or her full
story and reasons for seeking care. If 100 people wake up
with a bad headache, and 97 go to work but 3 seek care,
what underlying dimension prompted those decisions?

You have by then begun to give structure to the present
illness or problem, giving it a chronologic and sequential
framework. Unless there is urgency, go slowly, hear the
full story, and refrain from striking out too quickly on what
seems the obvious course of questioning. The patient will
take cues from you on the leisure you will allow. You must

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Alcohol. The CAGE questionnaire is one model for discuss-
ing the use of alcohol (Box 1.3). CAGE is an acronym for
Cutting down, Annoyance by criticism, Guilty feeling,
Eye-openers. Its use does not ensure absolute sensitivity
in the detection of a problem. It can be complemented or
supplemented by the TACE model (Box 1.4), particularly
in the identification of alcoholism in a pregnant patient
(because of the potential for damage to the fetus), or by
CRAFFT, for identification of an alcohol problem in ado-
lescents (Box 1.5). There is similarity in all of these question-
naires. You can adapt them to your style and to the particular
patient. You can also adapt them to concerns about drugs
or substances other than alcohol (see Clinical Pearl,
“Screening”).

• Ask for questions.
• Interpret and summarize what you have heard.
• Ask the patient to summarize for you to ensure complete

understanding.
• Repeat instructions and ask to hear them back.
• Explain the next steps: needed examinations and/or

studies, appointment times, keeping in touch.

Sensitive Issues
Sensitive issues, which may be difficult to discuss (e.g.,
sex, drug or alcohol use, concerns about death) are important
to address. The following guidelines, keys to any successful
interview, are essential in an approach to sensitive issues.
• Provide privacy.
• Do not waffle. Be direct and firm. Avoid asking leading

questions.
• Do not apologize for asking a question.
• Do not preach. Avoid confrontation. You are not there

to pass judgment.
• Use language that is understandable to the patient, yet

not patronizing (see Clinical Pearl, “Watch the Use of
Jargon”).

• Do not push too hard.
Afterward, document carefully, using the patient’s words
(and those of others with the patient) whenever possible.
It is all right to take notes, but try to do this sparingly,
especially when discussing sensitive issues.

CLINICAL PEARL

Watch the Use of Jargon
Unfortunately, many of us may too often lapse into the use of jargon,
the language of our profession that is not accessible to the patient.
Patient-demeaning words are worse. Stress, frustration, fatigue, and
anger are common underlying causes for these lapses. Know yourself.
Understand why you might fall into the habit, and do your best to
avoid it.

BoX 1.3 CAGE Questionnaire

The CAGE questionnaire was developed in 1984 by Dr. John Ewing,
and it includes four interview questions designed to help screen for
alcoholism.

The CAGE acronym helps practitioners quickly recall the main
concepts of the four questions (Cutting down, Annoyance by criticism,
Guilty feeling, Eye-openers).

Probing questions may be asked as follow-up questions to the
CAGE questionnaire.

Many online resources list the complete questionnaire (e.g., http://
addictionsandrecovery.org/addiction-self-test.htm). The exact wording
of the CAGE Questionnaire can be found in O’Brien CP. The CAGE
Questionnaire for Detection of Alcoholism. JAMA. 300:2054–2056, 2008.

From Sokol et al, 1989.

BoX 1.4 TACE Model

The following questions are included in the TACE model:
T How many drinks does it Take to make you feel high? How many

when you first started drinking? When was that? What do you
prefer: beer, wine, or liquor? (More than two drinks suggests a
tolerance to alcohol that is a red flag.)

A Have people Annoyed you by criticizing your drinking?
C Have you felt you ought to Cut down on your drinking?
E Have you ever had an Eye-opener drink first thing in the morning

to steady your nerves or get rid of a hangover?
An answer to T alone (more than two drinks) or a positive response

to two of A, C, or E may signal a problem with a high degree of
probability. Positive answers to all four signal a problem with great
certainty.

CLINICAL PEARL

Screening
There is a difference between a screening and an assessment interview.
The goal of screening is to find out if a problem exists. This is particularly
true of CAGE, CRAFFT, and TACE screening tools. They are effective,
but they are only the start, and assessment goes on from there. Discover-
ing a problem early may lead to a better treatment outcome.

You must always be ready to explain again why you
examine sensitive areas. A successful approach will have
incorporated four steps:
1. An introduction, the moment when you bring up the

issue, alluding to the need to understand its context in
the patient’s life.

2. Open-ended questions that first explore the patient’s
feelings about the issue—whether, for example, it is
alcohol, drugs, sex, cigarettes, education, or problems
at home—and then the direct exploration of what is
actually happening.

3. A period in which you thoughtfully attend to what the
patient is saying and then repeat the patient’s words or
offer other forms of feedback. This permits the patient
to agree that your interpretation is appropriate, thus
confirming what you have heard.

4. Finally, an opportunity for the patient to ask any questions
that might be relevant.

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CHAPTER 1 The History and Interviewing Process 9

These cover two dimensions of partner violence, and a
positive response to any one of them constitutes a positive
screen. The first question addresses physical violence. The
latter two questions evaluate the woman’s perception of
safety and estimate her short-term risk of further violence
and need for counseling.

Additionally, you may see something suggestive on
physical examination and ask the following: “The bruises
I see. How did you get them?”

Positive answers require accurate documentation, using
words, drawings, and, if possible, photographs and the pres-
ervation of any tangible evidence. Positive answers require
that the patient’s safety be ensured. Ask the following:
• Are you afraid to go home?
• Are there guns or knives at home?
• Is alcohol (or other drugs) part of the problem?
• Has it gotten worse lately?
• Are children involved?

A “yes” answer mandates an intervention that requires
utilization of other healthcare professionals such as social
workers and mental health providers who may be able to
provide more in-depth assessment and linkage to resources.
Get the patient’s viewpoint. Let her speak; assure her that
she is not alone and that you will do your best to help her.

A “no” answer may still leave you uncomfortable. Get
permission from the patient to document your concern
and your suspicion of injury. Be unafraid to ask direct
questions about your suspicion (“Where did that bruise
come from?”). Ask her to come back to see you again.

Intimate Partner Violence. We too often underestimate
the incidence of intimate partner violence (IPV) in the
experience of our patients of any age or gender identity.
IPV includes a range of abusive behaviors perpetrated by
someone who is or was involved in an intimate relationship
with the victim. It affects primarily women, children, and
dependent older adults as victims and, in lesser frequency,
men. Intimate partners are usually the perpetrators. Same-
sex partners probably have the same prevalence, although
underreporting may be more of a problem in this population.
Alcohol is a common facilitator. Children exposed to IPV
are at increased risk for social and emotional problems.
There is significant overlap between IPV and child abuse,
so when IPV is detected, child abuse should be considered.

Reluctance to screen for fear of offending patients and
families is a misplaced concern. This is occasionally
compounded by an inappropriate response to an abused
woman, such as making too little of her experience or even
laying the blame on her. She is, then, twice a victim. The
“she” is used advisably. Although IPV affects both men
and women as victims and perpetrators, more women
experience IPV (Nelson et al, 2012), and transgendered
women are at higher risk of physical and psychological
IPV than are cisgender adults (Pitts et al, 2006). Likewise,
lesbian, gay, bisexual, and transgender (LGBT) youth are
at high risk for being victims of IPV (Whitton et al, 2016).
Relatively few will discuss IPV willingly with a healthcare
provider, and, in that event, the patient is almost always
the initiator of the discussion. If a healthcare provider makes
the initial inquiry, it is usually asked in an emergency
department of a person who may have difficulty getting
out of an abusive relationship, a minority woman, or one
who is obviously vulnerable. All female patients should be
routinely screened in all healthcare settings (Moyer and
U.S. Preventive Services Task Force, 2013); however, we
recommend all indiviuals be screened. A validated brief
Partner Violence Screen (PVS) uses three questions to detect
partner violence (MacMillan et al, 2006):
1. Have you been hit, kicked, punched, or otherwise hurt

by someone within the past year?
2. Do you feel safe in your current relationship?
3. Is there a partner from a previous relationship who is

making you feel unsafe now?

BoX 1.5 CRAFFT Questionnaire

The CRAFFT questionnaire was developed in 2002 as a screening tool
for alcohol and substance abuse in adolescents.

The CRAFFT acronym helps practitioners remember the main
concepts of the six questions: Car, Relax, Alone, Forget, Friends,
Trouble.

The exact wording of the CRAFFT questions can be found here:
Knight JR et al. Validity of the CRAFFT Substance Abuse Screening
Test Among Adolescent Clinic Patients. Arch Pediatr Adolesc Med
156:607-614, 2002 (available online at http://archpedi.jamanetwork.
com/article.aspx?articleid=203511).

Evidence-Based Practice in Physical Examination

Screening for Abuse and Intimate Partner Violence
Data from a systematic review indicate that screening practices by
healthcare professionals are inconsistent for several reasons, including
the existence of a variety of screening instruments, a lack of consensus
on which instrument to use, lack of specificity of risk factors, lack of
training, lack of effectiveness studies about what to do if violence is
identified, discomfort with screening, and time constraints. Several
instruments have been developed for intimate partner violence screening,
and their diagnostic accuracy has been evaluated in studies of different
populations using various reference standards. Six instruments with
one to eight items demonstrated sensitivity and specificity greater
than 80% in clinical populations of asymptomatic women; results varied
between studies and across instruments. The Feldhaus PVS three-item
screening instrument had a higher sensitivity and specificity compared
with two longer instruments. The HITS (Hurt-Insult-Threaten-Scream)
four-item screening instrument for abuse (Box 1.6) demonstrated 86%
sensitivity and 99% specificity (English version) and 100% percent
sensitivity and 86% specificity (Spanish version).

Studies to develop and evaluate tools are generally lacking to
assess screening older and vulnerable adults for abuse. Existing
instruments to detect child abuse are not designed for direct administra-
tion to the child, missing opportunities to screen older children in the
context of usual health care.

Data from Nelson et al, 2004, and Kliegman et al, 2016.

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ss Spirituality. The basic condition that life imposes is death.
It often stirs in us a spiritual or “sacred” feeling—always
with us, frequently sublimated, sometimes not. Illness,
however mild, may stir that feeling and may carry with it
a sense of dread. Faith may be an intimate contributor to
one’s perspective. An understanding of “spirituality” is,
then, integral to the care we offer, but it is complicated by
the fact that there is no universally agreed-on definition;
each of us brings our own understanding to the care
provided.

Many patients want attention paid to spirituality, and
faith can be a key factor in the success of a management
plan. Others may prefer that you not broach the subject.
This requires the same degree of sensitivity and caution
as talking about drugs, cigarettes, sex, and alcohol. The
questions suggested by Puchalski and Romer (2000) with
the acronym FICA and adapted by us suggest an approach:
• Faith, Belief, Meaning

• What is your spiritual or religious heritage? Is the
Bible, the Quran, or similar writings important to
you?

• Do these beliefs help you cope with stress?
• Importance and Influence

• How have these beliefs influenced how you handle
stress? To what extent?

• Community
• Do you belong to a formal spiritual or religious com-

munity? Does this community support you? In what
way? Is there anyone there with whom you would
like to talk?

• Address/Action in Care
• How do your religious beliefs affect your healthcare

decisions (e.g., choice of birth control)? How would
you like me to support you in this regard when your
health is involved?

Answers to these questions may guide you to involve
the clergy or other spiritual care providers or to become
more deeply involved. There is some evidence that prayer
can aid in healing. You may, if you are asked and are
inclined, pray with a patient, although it is best that you
not lead the prayer. You may even suggest it if the patient
is sorely troubled and you understand the need. There are,
however, boundaries. Except for very few of us, we are not
theologians, and it is inappropriate to go beyond the limits
of our professional expertise.

Auster (2004) suggests sensitivity on our part when
patients ask about our personal beliefs and express their
wish to talk of this only with someone of their own faith.
You might say, “I want to help you as best I can, so please
tell me why you ask about my faith” or, more directly, “I
understand your feeling. Would it help if I found another
person for you?” Let your sense of the situation guide you
(Fosarelli, 2003; Puchalski and Romer, 2000).

Sexuality and Gender Identity
Patients should be told that discussion is routine and
confidential. Questions about the patient’s sexual history

The same approach works for men, but it is not neces-
sarily used routinely. His statements or a suspicious injury
may trigger your action. Infants and children have the
protection of the legal mandate for you to report your
suspicions. Questioning a child about abuse suffered or
witnessed at home can be problematic because you want
to avoid suggestion. In general, open-ended questions are
comfortably asked of the young or of a parent in their
presence:
• Why did you come to see me today? (Do not mention

the concern directly.)
• Tell me everything that happened to you, please. (No

leading questions.)
• With infants, a bruise or burn with an odd shape or

unexpected location is very concerning for child abuse.
It is difficult for an infant who is not yet crawling or
toddling to break a femur or to have finger print–size
bruises on the arms, for example.

• Adolescents may endure violence, particularly sexual,
at home or away. The clue may be changes in behavior,
such as dress and makeup, school effort, sleeping, and
eating. Routinely screen adolescents for partner violence.
Alcohol or drug use can become an issue. Former friends
may be avoided. Most important, take your time and
ask the following questions:
• Have you ever had sexual intercourse?
• When did you start?
• Did you want to, or were you forced or talked

into it?
• Do the people you are with ever scare you?
• Did anyone ever touch you in a sexual way?
Always be available for more conversation. The questions

are just a start. Note, too, that the young may also witness
as well as endure violence at home, with a profound effect
on their lives and behavior. These problems should be dealt
with as if the patient were the direct victim.

The risk of abuse of older adults, often underreported,
is greater if the older adult has had a history of mental
illness, is physically or cognitively impaired, or is living in
a dependent situation with inadequate financial resources.
The abusers may have similar risks, perhaps alcohol or
drug related. Both groups may well have a past history of
domestic violence. In any event, confront the issue with
an approach modeled on that for women in difficulty.

BoX 1.6 Brief Screening Tool for Domestic
Violence: HITS

Verbal abuse is as intense a problem as physical violence. HITS stands
for Hurt, Insult, Threaten, or Scream. The wording of the question is,
“In the past year, how often did your partner:
Hurt you physically?”
Insult or talk down to you?”
Threaten you with physical harm?”
Scream or curse at you?”

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CHAPTER 1 The History and Interviewing Process 11

Chief Concern or the Reason for Seeking Care. This answers
the question, “Why are you here?” (see Clinical Pearl, “Chief
Complaint or Chief Concern?”). Follow-up questions ask
about duration (e.g., “How long has this been going on?”
or “When did these symptoms begin?”). The patient’s age,
gender, marital status, previous hospital admissions, and
occupation should be noted for the record. Other concerns
may surface. A seemingly secondary issue may have greater
significance than the original concern because the driving
force for the chief concern may be found in it. What really
made the patient seek care? Was it a possibly unexpressed
fear or concern? Each hint of a care-seeking reason should
be thoroughly explored (Box 1.7).

may first be indirect, addressing feelings rather than facts.
“Are you satisfied with your sexual life, or do you have
worries or concerns? Many people do.” Although this is a
leading question, it does not suggest what the patient’s
feelings should be. Rather, if there are concerns about sex,
it may be comforting to know that one is not alone. The
age of the patient should not deter discussion. Do not
assume more or less for a given age, particularly older
adults.

It is also important to ask questions about a patient’s
sexual orientation and gender.

Identity. You should directly ask about patient’s prefer-
ences. In general, patients support healthcare providers
asking questions related to sexual orientation and gender
identity and understand the importance of healthcare
providers’ knowing their patients’ preferences (Cahill et al.,
2014).

The sexual orientation of a patient must be known if
appropriate continuity of care is to be offered. About 10%
of the persons you serve are likely to be other than hetero-
sexual (i.e., gay, lesbian, bisexual, or transgendered)
(Makadon, 2011; Ward et al., 2014). Working with sexual
minority individuals demands knowing yourself regarding
any potential feelings about heterosexism and homophobia
that you may have. The apprehension these patients may
feel in revealing their preferences should be respected.
Reassuring, nonjudgmental words help: “I’m glad you trust
me. Thank you for telling me.” It is also supportive if the
healthcare setting offers some recognition of the patients
involved (e.g., by making relevant informational pamphlets
available in waiting areas).
• Trust can be better achieved if questions are “gender

neutral”:
• Tell me about your living situation.
• Are you sexually active?
• In what way?

• Rather than:
• Are you married?
• Do you have a boyfriend/girlfriend?

If you use a nonjudgmental approach, a variety of questions
applicable to any patient and any sexual circumstance
becomes possible. The patient’s vernacular may be necessary.
Once the barrier is broken, you can be more direct, asking,
for example, about frequency of sexual intercourse, problems
in achieving orgasm, variety and numbers of “partners” (a
non–gender-linked term), masturbation, and particular likes
and dislikes. Identifying risk factors for unintentional
pregnancy and sexually transmitted infections (STIs) are
an important part of the sexual history.

Outline of the History
The outline offered is a guide derived over time from
multiple sources, formal and informal. It is not rigid, and
you can decide what meets the needs of your patient
and your style. Take advantage of patient’s photographs
and videos that complement what you learn in the history.

BoX 1.7 The Basis of Understanding

The following are vital questions that probe the unique experience of
each patient:
Why is this happening in the life of this particular person at this time?
How is this patient different from all other patients?
Can I assume that what is generally true for others is necessarily true

for this patient?
How does this bear on my ultimate interpretation of possible problems

and solutions?

CLINICAL PEARL

Chief Complaint or Chief Concern?
Many of us do not view patients as “complainers” and prefer to express
the “chief complaint” differently, adopting “chief concern,” “presenting
problem,” or “reason for seeking care” as a more appropriate term.
Feel free to use the words that suit you best or are most appropriate
in your healthcare setting.

History of Present Illness or Problem. You will often find
that it is easiest to question the patient on the details of
the current problem immediately after hearing the chief
concern. Sometimes it may be of value to take the patient’s
past and family history before returning to the present.
The specific order in which you obtain the patient’s story
is not critical. You want the patient’s version without the
use of leading questions. Box 1.8 suggests many of the
variables that can influence the patient’s version.

A complete HPI will include the following:
• Chronologic ordering of events
• State of health just before the onset of the present

problem
• Complete description of the first symptoms. The question

“When did you last feel well?” may help define the time
of onset and provide a date on which it might have been
necessary to stop work or school, miss a planned event,
or be confined to bed.

• Symptom analysis: Questions in the following categories
assist the patient in specifying characteristics of the
presenting symptom(s): location, duration, intensity,

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ss corrections (If there appears to be more than one
problem, the process should be repeated for each one.)

Past Medical History. The past medical history is the
baseline for assessing the present concern.
• General health and strength
• Gender identity: male, female, transmale, transfemale,

nonbinary; preferred pronoun; hormones and/or gender-
affirming surgeries

• Childhood illnesses: measles, mumps, whooping cough,
chickenpox, scarlet fever, acute rheumatic fever, diph-
theria, poliomyelitis, asthma

• Major adult illnesses or chronic diseases: tuberculosis,
hepatitis, diabetes, hypertension, myocardial infarction,
heart disease, stroke, respiratory disease, tropical or
parasitic diseases, other infections; any nonsurgical
hospital admissions

• Immunizations: polio; diphtheria, pertussis, and tetanus
toxoid; influenza; hepatitis A; hepatitis B; rotavirus,
measles, mumps, rubella; varicella; herpes zoster vaccine;
pneumococcus; meningococcus; human papillomavirus;
bacille Calmette-Guérin; last tuberculosis or other skin
tests; unusual reactions of any sort to immunizations or
travel-related immunizations [e.g., typhoid, yellow fever]

• Surgery: dates, hospital, diagnosis/indication, complica-
tions; gender-affirming surgeries

• Serious injuries and resulting disability; obtain complete
details if present problem has potential medicolegal
relation to an injury

• Limitation of ability to function as a result of past events
• Medications: past, current, and recent medications,

including dosage of prescription and home remedies
and nonprescription medications (when not mentioned
in present problem); gender identity hormone use

• Allergies and the nature of reactions, especially to
medications, but also to environmental allergens and
foods

• Transfusions: reactions and the nature of reactions, date,
and number of units transfused

• Recent screening tests (e.g., cholesterol, Pap smear,
colonoscopy, mammogram)

• Emotional status: mood disorders, psychiatric problems

description/character, aggravating factors, alleviating
factors.

• Description of a typical attack, including its persistence.
If the present problem involves intermittent attacks
separated by an illness-free interval, ask the patient to
describe a typical attack (e.g., onset, duration, variation
in intensity and associated symptoms, such as pain,
chills, fever, jaundice, hematuria, or seizures) and any
variations. Then ask the patient to define inciting,
exacerbating, or relieving factors such as specific activi-
ties, positions, diet, or medications.

• Possible exposure to infection, toxic agents, or other
environmental hazards

• Impact of the illness on the patient’s usual lifestyle (e.g.,
sexual experience, leisure activity, ability to perform tasks
or cope with stress), an assessment of the ability to
function in the expected way with an indication of the
limitations imposed by illness

• Immediate reason that prompted the patient to seek
care, particularly if the problem has been long-standing

• Appropriate relevant system review
• Medications: current and recent, including dosage of

prescription, home remedies, and nonprescription
medications

• Use of complementary or alternative therapies and
medications

• A review, at the end of the interview, of the chronology
of events, seeking the patient’s confirmations and

BoX 1.8 Factors That Affect the Patient’s
Expression of Illness

Disease is a real condition that prevents the body or mind from working
normally (Merriam-Webster.com). Illness is the unique way in which
a disease is expressed by the afflicted individual. An infinite number
of variables come into play and may even cause illness without disease:
• Recent termination of a significant relationship because of death,

divorce, or other stressors such as moving to a new city
• Physical or emotional illness or disability in family members or

other significant individuals
• Inharmonious spousal or family relationships
• School problems and stresses
• Poor self-image
• Drug and alcohol misuse
• Poor understanding of the facts of a physical problem and its

treatment
• Influence from social media
• Peer pressure (among adults as well as adolescents and

children)
• Secondary gains from the complaints of symptoms (e.g., indulgent

family response to complaints, providing extra comforts or gifts,
solicitous attention from others, distraction from other intimidating
problems)
At any age, such circumstances can contribute to the intensity

and persistence of symptoms or, quite the opposite, the denial of an
insistent, objective complaint. The patient may then be led to seek
help or, at other times, to avoid it.

Evidence-Based Practice in Physical Examination

History Taking
There is evidence that the risk for type 2 diabetes or cardiovascular
disease is detectable in childhood and that the diseases share risk
factors, including obesity and dyslipidemia. Other studies suggest that
these risks can be reduced in childhood. The pathway to detecting
risk is the family history. Adults with one or more second-degree relatives
with diabetes or cardiovascular disease are at high risk. So, too, are
children with similar histories. The family history provides insight into
the genetic effects on health and disease and offers clues that can
lead to prevention strategies.

From Yang et al, 2010.

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CHAPTER 1 The History and Interviewing Process 13

cigarette use can be reported in “pack-years,” the number
of packs a day multiplied by the number of years (e.g.,
1.5 packs per day × 10 years = 15 pack-years; see Evidence-
Based Practice in Physical Examination, “Smoking
Cessation”).

• Self-care: use of home, herbal, natural, complementary
or alternative therapies/exercise (quantity and type)

• Sexual history: concerns with sexual feelings and per-
formance, frequency of intercourse, ability to achieve
orgasm, number and variety of partners, specific sexual
practices, modes of birth control, protection against STIs
and past STIs. (“Partner” is a gender-free term, appropri-
ate in the early stages of discussion; see Clinical Pearl,
“The Five Ps of a Sexual History.”)

Family History. Blood relatives in the immediate or
extended family with illnesses with features similar to the
patient’s are an immediate concern. If a disease “runs in
the family,” such as sickle cell disease, ask about everyone
from grandparents to cousins and children. A pedigree
diagram helps illustrate the family members with the
disorder (see Chapter 5). A thorough and well-done family
history is the essence of genetics (Pyeritz, 2012). Determine
the health and, if applicable, the cause of death of first-degree
relatives (parents, children, and siblings), including age at
death; after that, second-degree relatives (grandparents,
grandchildren, aunts, nieces, uncles, and nephews); and
then third-degree relatives (first cousins). There should be
at least three generations in the pedigree.
• Include the following in your list of concerns: heart

disease, high blood pressure, cancer (including the type),
tuberculosis, stroke, sickle cell disease, cystic fibrosis,
epilepsy, diabetes, gout, kidney disease, thyroid disease,
asthma or other allergic condition, forms of arthritis,
blood diseases, STIs, familial hearing, and visual or other
sensory problems.

• In particular, determine whether cancers have been
multiple, bilateral, and occurring more than once in the
family and at a young age (younger than age 50 years).

• Note the age and outcome of any illness.
• Note the ethnic and racial background of the family.
• Note the age and health of the patient’s spouse/partner

or the child’s parents.

Personal and Social History
• Personal status: birthplace, where raised, home environ-

ment when young (e.g., parental divorce or separation,
socioeconomic class, cultural and ethnic background),
education, position in family, marital status, general life
satisfaction, hobbies and interests, occupation, activities,
sources of stress or strain (see Clinical Pearl, “Who
Are You?”)

CLINICAL PEARL

Who Are You?
We cannot assume how patients define themselves ethnically or cultur-
ally without asking them. “Hispanic,” “non-Hispanic,” “black,” “white,”
“Latino,” and “Asian,” among many other designations, are subject
to a variety of interpretations. Just ask, “How do you see yourself?”
“How do you define yourself?” “I respect your values and beliefs; what
do I need to know to provide care for you?” Remember not to stereotype
just because a patient is a member of a culture. Each person is his
or her own unique culture.

• Habits: nutrition and diet; regularity and patterns of
eating and sleeping; quantity of coffee, tea, tobacco,
alcohol; use of street drugs (e.g., frequency, type, and
amount); ability to perform activities of daily living (see
Functional Assessment for All Patients). The extent of

CLINICAL PEARL

The Five Ps of a Sexual History
The five Ps stand for:
• Partners
• Practices
• Protection from STIs
• Past history of STIs
• Prevention of pregnancy (if necessary)

These are the areas that you should openly discuss with your
patients. You will probably need to ask additional questions that are
appropriate to each patient’s special situation or circumstances.

(From Centers for Disease Control and Prevention [2012]. Guide to Taking a Sexual History.
Available at: http://www.cdc.gov/std/treatment/SexualHistory.pdf.)

• Home conditions: housing, economic condition, types
of furnishings (e.g., carpeting and drapes), pets and their
health

• Occupation: description of usual work (and present work
if different); list of job changes; work conditions and
hours; physical or mental strain; duration of employment;
present and past exposure to heat and cold or industrial
toxins (especially lead, arsenic, chromium, asbestos,
beryllium, poisonous gases, benzene, and polyvinyl
chloride or other carcinogens and teratogens); any protec-
tive devices required (e.g., goggles or masks); excessive
screen time

• Environment: travel and other exposure to contagious
diseases, residence in tropics, water and milk supply,
other sources of infection if applicable

• Military record: dates and geographic area of assignments
• Religious and cultural preferences: any religious proscrip-

tions concerning food, medical care; spiritual needs
• Access to care: transportation and other resources avail-

able to patient, type of health insurance coverage (if
any), worries in this regard, primary care provider,
customary pattern of seeking care

• Social needs: insurance/medication coverage, food
insecurity, housing instability, employment assistance
needs
It is important to have candid discussion of issues.

14 CHAPTER 1 The History and Interviewing Process
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ss • Breasts: development, pain, tenderness, discharge, lumps,
galactorrhea, mammogram results

• Heart and blood vessels: chest pain or distress, precipitat-
ing causes, timing and duration, relieving factors, palpita-
tions, dyspnea, orthopnea (number of pillows needed),
edema, hypertension, previous myocardial infarction,
estimate of exercise tolerance, past electrocardiogram
or other cardiac tests and their results

• Peripheral vasculature: claudication—frequency, severity,
tendency to bruise or bleed, thromboses, thrombophlebitis

• Hematologic: anemia, bruising, any known abnormality
of blood cells

• Gastrointestinal: appetite, digestion, intolerance for any
class of foods, dysphagia, heartburn, nausea, vomiting,
hematemesis; regularity of bowels, constipation, diarrhea,
change in stool color or contents (e.g., clay-colored, tarry,
fresh blood, mucus, undigested food); flatulence, hemor-
rhoids; jaundice, history of ulcer, gallstones, polyps,
tumor; previous diagnostic imaging (indication, where,
when, results)

• Diet: appetite, likes and dislikes, restrictions (e.g., prefer-
ential, religious, allergy, or other disease), vitamins and
other supplements, use of caffeine-containing beverages
(e.g., coffee, tea, and cola); an hour-by-hour detailing
of food and liquid intake (sometimes a written diary
covering several days of intake may be necessary)

• Endocrine: thyroid enlargement or tenderness, heat or
cold intolerance, unexplained weight change, diabe-
tes, polydipsia, polyuria, distribution and changes in
facial or body hair, increased hat and glove size, skin
striae

• Genitourinary: dysuria, flank or suprapubic pain, urgency,
frequency, nocturia, hematuria, polyuria, dark or dis-
colored urine, hesitancy, dribbling, loss in force of stream,
passage of stone; edema of face; stress incontinence;
hernias; STIs (type, laboratory confirmations, and
treatment)

• Musculoskeletal: joint stiffness, pain, restriction of
motion, swelling, redness, heat, bony deformity

• Neurologic: syncope, seizures, weakness or paralysis,
abnormalities of sensation or coordination, tremors, loss
of memory

• Psychiatric: depression, mood changes, difficulty con-
centrating, anxiety, agitation, tension, suicidal thoughts,
irritability, sleep disturbances
Females and Transmales

• Menses: age at menarche, regularity, duration and amount
of flow, dysmenorrhea, last menstrual period (LMP),
intermenstrual discharge or bleeding, itching, date of
last Pap smear and/or HPV test and result, age at
menopause, libido, frequency of intercourse, pain during
intercourse, sexual difficulties, infertility

• Pregnancies: number, living children, multiple births,
miscarriages, abortions, duration of pregnancy, each type
of delivery, any complications during any pregnancy or
postpartum period or with neonate; use of oral or other
contraceptives

Review of Systems (ROS). Identify the presence or absence
of health-related issues in each body system. You may not
ask all of the questions relevant to each system each time
you take a given patient’s history. Nevertheless, many should
be asked, particularly at the first interview. A targeted ROS
is appropriate in some circumstances. More comprehensive
questions for particular circumstances in each system are
detailed in subsequent chapters. Negative responses to ROS
questions are as important as positive responses.
• General constitutional symptoms: pain, fever, chills,

malaise, fatigue, night sweats, sleep patterns, weight
(i.e., average, preferred, present, change)

• Skin, hair, and nails: rash or eruption, itching, pigmenta-
tion or texture change; excessive sweating, abnormal
nail or hair growth

• Head and neck
• General: frequent or unusual headaches, their location;

dizziness, syncope, severe head injuries; concussions,
periods of loss of consciousness (momentary or
prolonged)

• Eyes: visual acuity, blurring, diplopia, photophobia, pain,
recent change in appearance or vision; glaucoma; use
of eye drops or other eye medications; history of trauma

• Ears: hearing loss, pain, discharge, tinnitus, vertigo,
infections

• Nose: sense of smell, frequency of colds, obstruction,
epistaxis, postnasal discharge, sinus pain

• Throat and mouth: hoarseness or change in voice,
frequent sore throats, bleeding or swelling of gums,
recent tooth abscesses or extractions, soreness of tongue
or buccal mucosa, ulcers, disturbance of taste, dental
care

• Lymph nodes: enlargement, tenderness, suppuration
• Chest and lungs: pain related to respiration; dyspnea,

cyanosis, wheezing, cough, sputum (character and
quantity), hemoptysis, night sweats, exposure to
tuberculosis; indication, date and result of last chest
x-ray

Evidence-Based Practice in Physical Examination

Smoking Cessation
Abundant evidence indicates that patients in a trusting relationship
with nurses, physicians, or other health professionals will respond
positively to even brief, simple advice about smoking cessation.

Pooled data from 17 trials of brief advice versus no advice (or
usual care) detected a significant increase in the rate of quitting (relative
risk [RR] 1.66). Among 11 trials where the intervention was more
intensive, the estimated effect was higher (RR 1.84), but there was
no statistical difference between the intensive and minimal subgroups.
Direct comparison of intensive versus minimal advice showed a small
advantage of intensive advice (RR 1.37). The bottom line is that it pays
to offer even minimal advice if given respectfully and earnestly. Simple
advice has an effect on cessation rates. The challenge is to incorporate
smoking cessation interventions as part of standard practice.

(From Stead et al, 2013.)

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CHAPTER 1 The History and Interviewing Process 15

Family dynamics become evident during history taking
and may even lead to clues that a parent is in need of help.
For example, an excessively tearful parent who does not
seem to be having much pleasure in a child or seems
self-absorbed, unresponsive, and uncommunicative—or
even hostile—may be depressed. Your responsibility goes
beyond the child. It is appropriate to screen the mother
for depression (Weiss-Laxer et al, 2016) and suggest ways
to help (see Chapter 7). Respect parental concerns about
their children, and do what is needed to ease worry.

There are aspects of the history concerning the young
that may complement the approach suggested for adults
or vary from it. They are as follows.

Chief Concern. A parent or other responsible adult (Box
1.9) often makes a threesome. The relationship of that
person should be recorded. However, the child should be
included as much as possible and as is age appropriate.
The latent fears underlying any chief concerns of the adults
and children should be explored.

History of Present Illness. The degree and character of the
reaction to the problem on the part of parent/guardian and
child should be noted.

Past Medical History
• Note general health and strength: age of the child and/

or the nature of the problem determine the approach
to questioning

• Patient’s health during pregnancy:
• General health as related by the patient if possible,

extent of prenatal care, gravidity, parity
• Specific diseases or conditions: infectious disease

(approximate gestational month), weight gain, edema,
hypertension, proteinuria, bleeding (approximate
gestational month), preeclampsia

• Medications, hormones, vitamins, special or unusual
diet, general nutritional status

• Quality of fetal movements and time of onset
• Emotional and behavioral status (e.g., attitudes toward

pregnancy and children)
• Radiation exposure
• Use of recreational drugs

• Birth
• Duration of pregnancy
• Place of delivery

Males and Transfemales
• Puberty onset, difficulty with erections, emissions,

testicular pain, libido, infertility

Concluding Questions. Give the patient further opportunity.
“Is there anything else that you want me to know?” If there
are several issues, ask, “What problem concerns you most?”
When situations are vague, complicated, or contradictory,
it may be helpful to ask “What do you think is the matter
with you?” or “What worries you the most about how you
are feeling?”

Adaptations for Age, Pregnancy, and
Possible Disabilities
There are pervasive concerns common to all patients,
particular concerns common to some, and unique concerns
that distinguish any one individual.

Infants and Children
Many children love it when you get down on the floor to
play with them. They often have anxieties and fears that
must be eased (Fig. 1.3). Use language that they understand.
When they are old enough, allow them to actively participate
in the interview. Starting at age 7 years, children can be
dependable reporters on aspects of their health (Olson et al,
2007). The older the child, the more productive it becomes
to ask questions and to give information directly. The older
child and the adolescent may seem passive and sometimes
appear hostile to some degree. This may suggest a wish
to be alone with you, which may help to get a more accurate
history. Be proactive and arrange for this routinely (see
Clinical Pearl, “Twins or More”).

FIg. 1.3 Interviewing a child with his parent. Note that the interviewer
is sitting close to the patient and that the child is secure on his parent’s
lap.

CLINICAL PEARL

Twins or More
Your patients may be twins, triplets, or more! Each is an individual
entitled to separate consideration. Ensure that each has confidential
and separate time with you.

BoX 1.9 Consent by Proxy

Infants, children, and many adolescents are minors. They may come
to you accompanied by someone other than their custodial parent or
guardian, often a grandparent or other member of their extended
family. Sometimes your informant might be a babysitter, an au pair
or nanny, or, in the event of divorce and remarriage, a noncustodial
parent, stepparent, or friend. Does that person have the right to consent
to your care for the child? Learn about the policy and procedure for
consent in your healthcare setting.

16 CHAPTER 1 The History and Interviewing Process
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ss Expand the list when indicated. Parents may have baby
books, which can stimulate recall, or photographs may be
helpful. Additional developmental information to inquire
about includes the following:

• Age when toilet-trained: approaches to and attitudes
regarding toilet training

• School: grade, performance, problems
• Dentition: age of first teeth, loss of deciduous teeth,

eruption of first permanent teeth; last dental visit
• Growth: height and weight in a sequence of ages;

changes in rates of growth or weight gain
• Pubertal development: present status. In females,

development of breasts, nipples, sexual hair, menstrua-
tion (onset, cycle, regularity, pain, description of
menses), acne; in males, development of sexual hair,
voice changes, acne, nocturnal emissions

• Puberty suspention/supression in gender-
nonconforming minors

• Illnesses: immunizations, communicable diseases,
injuries, hospitalizations

Family History
• Pregnant patient’s gestational history listing all pregnan-

cies, together with the health status of living children.
For deceased children, include date, age, cause of death,
and dates and duration of pregnancies in the case of
miscarriages.

• Patient’s health during pregnancies and the ages of
parents at the birth of this child.

• Are the parents consanguineous? Again, a pedigree
diagram helps (see Chapter 5).

Personal and Social History
• Behavioral status: child care or school adjustment;

masturbation, nail biting, thumb sucking, breath holding,
temper tantrums, pica, tics, rituals; bed wetting, constipa-
tion or fecal soiling of pants; playing with fire; reactions
to prior illnesses, injuries, or hospitalization

• An account of a day in the life of the patient (from
parent, child, or both) is often helpful in providing
insights. Box 1.10 emphasizes the particular needs of
children who are adopted or are in foster care.

• Family circumstances: parents’ occupations, the principal
caretakers of the child, whether parents are divorced or
separated, educational attainment of parents; spiritual
orientation; cultural heritage; food preparation and by
whom; adequacy of clothing; dependence on relief or
social agency

• Setting of the home: number of rooms in house and
number of persons in household; sleep habits, sleeping
arrangements available for the child, possible environ-
mental hazards

Review of Systems. In addition to the usual concerns, inquire
about any past medical or psychologic or education testing
of the child (Box 1.11). Ask about the following:
• Skin: eczema, seborrhea, “cradle cap”

• Labor: spontaneous or induced, duration, analgesia
or anesthesia, complications

• Delivery: presentation, forceps, vacuum extraction,
spontaneous, or cesarean section; complications

• Condition of infant, time of onset of cry, Apgar scores
if available

• Birth weight of infant

Patient safety

Putting Prevention Into Practice
Take time to consider prevention. Consider how you can include
prevention-related advice when talking with your patient or surrogate.
For example, infants should sleep alone on their backs in a crib or
bassinet to decrease the risk of sudden infant death syndrome. In
addition, too often, child safety seats are used incorrectly. Their correct
use should be reviewed.

• Neonatal period
• Congenital anomalies; baby’s condition in hospital,

oxygen requirements, color, feeding characteristics,
vigor, cry; duration of baby’s stay in hospital and
whether infant was discharged with the patient who
gave birth; bilirubin phototherapy; prescriptions (e.g.,
antibiotics)

• First month of life: jaundice, color, vigor of crying,
bleeding, convulsions, or other evidence of illness

• Degree of early bonding: opportunities at birth and
during the first days of life for the parents to hold,
talk to, and caress the infant (i.e., opportunities for
both parents to relate to and develop a bond with the
baby)

• The feelings of the patient after giving birth: loss
of laughter; unreasonable anxiety or sense of panic;
excessive crying and sadness; sleeplessness; feelings of
guilt; suicidal ideation, clues singly but most often in
combination may be related to postpartum depression

• Feeding
• Formula or breast milk, reason for changes, if any; type

of formula and how it is prepared, amounts offered
and consumed; frequency of feeding and weight gain

• Present diet and appetite; age of introduction of solids;
age when child achieved three feedings per day;
present feeding patterns, elaboration of any feeding
problems; age weaned from bottle or breast; type of
milk and daily intake; food preference; ability to feed
self; cultural variations

• Development: Obtain the age when the child achieved
common developmental milestones:
• Holds head erect while in sitting position
• Rolls over from front to back and back to front
• Sits alone and unsupported
• Stands with support and alone
• Walks with support and alone
• Uses words
• Talks in sentences
• Dresses self

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CHAPTER 1 The History and Interviewing Process 17

reluctant to talk and have a clear need for confidentiality.
All adolescent patients should be given the opportunity to
discuss their concerns with you privately. It is wise to let
the parent or other caregiver know you will be asking them
to step out of the room to provide this important opportunity
for the adolescent. The visit can be an opportunity to provide
a safe space for teens to talk with their caregivers about
sensitive issues with your support. Every effort should be
made to maintain confidentiality. The limits regarding
confidentiality should be clearly discussed. Information
that suggests the adolescent’s safety or the safety of another
is at risk may be reasons to “break” confidentiality.

If a parent/guardian is present, acknowledge the patient
first. In the beginning it is helpful to talk about what is
happening in the patient’s day-to-day experiences. Do not
force conversation because adolescents do not respond
readily to confrontation. On the other hand, you will often
sense a need to talk and an inability to get the words out.
Silences can be long, sometimes sheepish, occasionally
angry, and not always constructive.

The peer group and the desire to be like peers take on
a dominant role during middle adolescence. Experimentation
with risky behaviors begins, and frequent arguments with
parents are common. Immature decision making can lead
to destructive, life-changing experiences and lifelong bad
habits. During late adolescence with approaching adulthood,
a more thoughtful consideration of consequences ordinarily
occurs, along with a more secure sense of self and an ability
to establish intimate relationships and to start planning a
career.

The adoption of risky behaviors depends on a number
of factors:
• Peer pressure
• Loosening attachment to parents
• Poor school performance
• Nonparticipation in school extracurricular activities
• Poor self-esteem
• Need to act older
• Susceptibility to advertising, the internet, or social media

These issues may make it difficult to transcend the barrier
imposed by age in caring for the adolescent (see Clinical
Pearl, “Identification of Concerns by Adolescents”). Make
generous use of open-ended questions, and do not force
an adolescent to talk.

• Ears: otitis media (frequency, laterality)
• Nose: snoring, mouth breathing, allergic reaction
• Teeth: dental care
• Genitourinary: bedwetting

Adolescents
Adolescence, the time from puberty to maturity, is different
from childhood and adulthood both physically and psycho-
socially. It is a time made vulnerable by a tendency to
experiment with risky behaviors. Adolescents may be

BoX 1.10 Adoption and Foster Care

Patients who are adopted or in foster care may not have a sufficient
history available. Learn as much as you can. Our outline for history
taking is a starter and should be filled out by an exploration of the
circumstances that led to adoption or foster care. Do this with care.
Some adoptive parents may not yet have shared the knowledge with
their children. The trials of the adoptive parents as they sought a
child, the process of adoption, the country of origin of the adoptee,
and the particular concerns of all involved must be explored.

The needs of foster children vary considerably from those who
are adopted. The history may be offered by a social worker, and the
issues you encounter will differ in variety and intensity. Foster parents
have varying experience, and foster children have often lived in more
than one home. Invariably, difficult social circumstances underlie the
separation from their parents. The probable lack of stability and security
and incomplete knowledge of past illnesses or other conditions make
it more difficult to understand the full range of the child’s complex
and urgent needs.

Modified from Augustyn et al, 1995. Reprinted with permission from Contemporary Pediatrics,
vol 12, 1995. Contemporary Pediatrics is a copyrighted publication of Advanstar Communica-
tions Inc. All rights reserved.

BoX 1.11 Violence or Traumatic Events in
Childhood

Witnessing or experiencing violence or injury is a fact of life for many
children and is a barrier to appropriate growth and development. Talk
about the event in a straightforward, simple, and direct fashion:
• Can you tell me what happened?
• What did you see? What did you hear?
• What scared you the most?
• What were you doing when it happened?
• Do you ever dream about it?
• Do you think about it during the day?
• Do you worry it will happen again?
• Whom do you talk to when you feel worried or scared?
• Why do you think it happened?
• For the older child and adolescent:
• How do you think it changed your life?

These questions are not value-laden and are not too constraining.
The child is free to talk if you can be comfortable with the silences
that may often ensue. Parents can also respond to the same questions
to fill out the story, and you can then learn how they dealt with the
circumstance and what they observed in their child’s behavior.

CLINICAL PEARL

Identification of Concerns by Adolescents
Previsit screeners or questionnaires allow the adolescent to identify
his or her concerns prior to the start of the visit. Sometimes allowing
an opportunity to write a concern or allowing a choice of concerns
presented in written, silent fashion may help (Box 1.12). Then you can
phrase the appropriate questions and make the transition to a verbal
discussion reasonably comfortable. Take an open-ended approach,
always indicating a sense of alliance and partnership.

18 CHAPTER 1 The History and Interviewing Process
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Pregnant Patients
Care during the prenatal period depends on the commitment
of the patient to both patient and fetal health, in partnership
with the healthcare provider. The patient’s approach to
pregnancy is influenced by many factors, including previous
experiences with childbearing and childrearing; the relation-
ship with the patient’s parent and other individuals signifi-
cant to the patient’s life; the patient’s desire for children;
and the patient’s present life circumstances. The interaction
of the patient with the fetus increases the complexity of
care. The initial interview includes past history, assessment
of health practices, identification of potential risk factors,
and assessment of the patient’s knowledge, expectations,
and perceptions as they affect pregnancy.

If you use an electronic device or preprinted history
form to gather the history, bridge the distance by talking
comfortably and at some length with the patient, particularly
the patient’s expectations and concerns. There will, of course,
be much “laying on of hands” as the pregnancy matures.

Basic Information
• Patient’s age, ethnicity
• Marital status, partner, or relationship

Flexibility, respect, and confidentiality are key; otherwise,
little productive discussion will result. On occasion, the
patient may ask to talk with someone of the same gender,
and this should be facilitated if possible. Box 1.13 provides
useful screening tools for adolescent issues. You can use
them as a guide for an exploratory interview. Some questions
that you can ask to structure the interview include the
following:
• “How are things at home?” “Tell me about your living

situation.” Do not assume the family structure. Do not
ask directly about who else lives in the house. The open-
ended question at the start can lead to greater specifics
later on.

• “How is school?” “Are you working?” “What is it about
school that appeals to you?” “What is it about school that
doesn’t appeal to you?” You may expect to hear somewhat
more about jobs outside of school and ideas about the
future when the patient approaches 20 years of age.

• “Tell me about your friends.” “Where do you go with
them?” “What do you do with them?” “To what groups
do you belong?” “How would a friend describe you?”

• “What types of computer and electronic games do you
play?”

• “What are you good at doing?”
Open-ended conversations about home, school, jobs,

activities, and friends can suggest the areas that may trouble
the adolescent (e.g., sex, drugs, bullying, suicidal ideation).
Talk does not always flow easily as the adolescent transitions
from dependency to independency, from parent/guardian
to peer group, and ultimately to self, but you can help.

BoX 1.12 Adolescents’ Concerns

The following subjects list may be of concern to adolescents. These
are highly charged issues mandating the effort for discussion but
requiring sensitivity, knowledge of adolescent language, and an unforced
approach.
• Bed wetting
• Menstrual pain
• Concern with height or weight: too short, too tall, underweight,

overweight
• Concern with breast size: too big, too small
• Concern with penis size: too small
• Worry about pregnancy
• Worry about sexual preference
• Concern about gender identity
• Interpersonal violence
• Sex? Ready or not?
• HIV, AIDS
• Gambling
• Smoking
• Substance use and abuse
• Parents’ attitudes and demands
• Friends and their pressures
• Bullying
• School: not doing well, excessive work
• What am I going to do in life?
• Thoughts about dying

From Goldenring and Rosen, 2004. Reprinted with permission from Contemporary Pediatrics,
vol 12, 2004, pp. 64-90. Contemporary Pediatrics is a copyrighted publication of Advanstar
Communications Inc. All rights reserved.

BoX 1.13 Screening Tools for Adolescent Issues

HEEADSSS
• Home environment
• Education, employment
• Eating
• Activities (peer-related), affect, ambitions, anger
• Drugs
• Sexuality
• Suicide/depression
• Safety from injury and violence

PACES
• Parents, peers
• Accidents, alcohol/drugs
• Cigarettes
• Emotional issues
• School, sexuality

CRAFFT: (Car, Relax, Alone, Forget, Friends, Trouble) (Knight
et al, 2002)
• Have you ridden in a CAR driven by someone who was high or

had been using drugs and alcohol?
• Do you ever use alcohol or drugs to RELAX, feel better about

yourself, or fit in?
• Do you ever use drugs or alcohol when you are ALONE?
• Do you FORGET things you did while using drugs or alcohol?
• Do your family and FRIENDS ever tell you that you should cut

down your drinking or drug use?
• Have you ever gotten into TROUBLE while using drugs or alcohol?

NOTE: HEEADSSS, PACES, and CRAFFT are screening tools and are not substitutes for
earnest conversation in a trusting relationship.

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CHAPTER 1 The History and Interviewing Process 19

Personal and Social History. Other children, pets (cats can
carry toxoplasmosis, which be teratogenetic to the fetus).
In addition, obtain information about feelings toward the
pregnancy, whether it was planned, consideration of adop-
tion or abortion, gender preference, social and spiritual
resources, experiences with parenting, experience with and
plans for labor and breast-feeding, and history of past or
present abuse in relationships (intimate partner violence).

Review of Systems. Perform a complete review of all systems
because the effects of pregnancy are seen in all systems.
Give special attention to the reproductive system (including
breasts) and cardiovascular systems (documentation of
prepregnancy blood pressure if possible). Assess the
endocrine system for signs of diabetes and thyroid dysfunc-
tion. Assess the urinary tract for infection, and review kidney
function. Assess respiratory function because it may be
compromised later in pregnancy or with tocolytic therapy
for preterm labor. Evaluate dental care needs because
treatment of periodontitis can prevent preterm birth and/
or low birth weight (George et al, 2011).

Risk Assessment. Identify conditions from the history and
physical examination or circumstances that threaten the well-
being of the patient and/or fetus. These include gestational
diabetes, preterm labor, preeclampsia/eclampsia, pregnant
patient malnutrition and vitamin deficiency, and use of
potentially teratogenetic agents such as lithium valproic
acid or angiotensin-converting enzyme inhibitors.

Postpartum. Postpartum depression is a significant mental
health problem, and universal screening for this problem
is recommended (see Chapter 7). The clues are similar to
those of depression in other circumstances—feeling down,
depressed, or hopeless, sleep disturbance, loss of energy,
eating disturbance, trouble concentrating, restlessness, sad
mood, anxiety, fatigue, feelings of worthlessness, inappropri-
ate guilt, and suicidal ideation. A cluster of these symptoms
should strongly postpartum depression (O’Connor et al,
2016; O’Hara and McCabe, 2013).

Older Adults
A change in knowledge, experience, cognitive abilities, and
personality may occur with aging (Box 1.14). It is important
to anticipate the effect these changes may have on the
interview. However, physiologic age and chronologic age
may not match. It is equally important to recognize that not
all adults experience the same changes, they do not occur at
the same rate, and some abilities may not decline with age.

Some older adults have sensory losses, such as hearing,
that make communication more difficult. Position yourself
so that the patient can see your face. Speak clearly and
slowly, taking care to always face the patient while you are
talking. Shouting magnifies the problem by distorting
consonants and vowels. In some instances, a written
interview may be less frustrating. Impaired vision and
light-dark adaptation are a problem with written interview

• LMP
• Previous usual/normal menstrual period (PUMP or

PNMP)
• Expected date of confinement/delivery (EDC)
• Occupation
• Parent(s) of the baby and his/her occupation (if

applicable)

History of Present Illness or Problem. Obtain a description
of the current pregnancy, and identify previous medical
care. Identify specific problems (e.g., bleeding or spotting,
nausea, vomiting, fatigue, or edema). Include information
about illness, injuries, surgeries, or accidents or other
injuries since conception.

Obstetric History. Information on each previous preg-
nancy (gravidity and parity) includes the date of delivery;
length of pregnancy; weight and gender of infant(s); type
of delivery (e.g., spontaneous vaginal; cesarean delivery
and type of scar [an evaluation of the competency of the
scar is needed for women attempting vaginal birth after
cesarean delivery]); or spontaneous, therapeutic, or elec-
tive abortion and the type of procedure; length of labor;
and complications in pregnancy or labor, postpartum, or
with the infant. It is also important to determine whether
any previous children have been removed from the home
(i.e., due to abuse or neglect or inability to care for the
children).

Menstrual History. In addition to previous information,
include age at menarche, characteristics of the cycle, unusual
bleeding, and associated symptoms. If known, include dates
of ovulation and conception, and the use of contraceptives
before or during conception.

Gynecologic History. Record the date of the most recent
Pap smear and human papilloma virus (HPV) test along
with any history of abnormalities, treatments, or gynecologic
surgery. A sexual history includes age of first intercourse
and whether it was consensual, number of sex partners,
safe-sex methods, partner orientation, and, if a minor, age
of partner. Information regarding the types of contraceptives
used and reason for discontinuing them, along with plans
for use postpartum, is obtained. Any history of infertility
should be explored. If any STIs are reported, discuss the
type, dates, treatments, and complications. Give full attention
to any history of sexual assault.

Past Medical History. The same information identified
previously for adults is obtained, with the addition of risk
factors for HIV, hepatitis, herpes, tuberculosis, and exposure
to environmental and occupational hazards.

Family History. Obtain a family history of genetic condi-
tions, multiple births, gestational diabetes, preeclampsia/
eclampsia or pregnancy-induced hypertension (PIH), and/
or congenital anomalies.

20 CHAPTER 1 The History and Interviewing Process
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ss Routinely include functional assessment as part of
the older adult’s history (see “Functional Assessment
for All Patients” and individual chapters with functional
assessment specific to systems). Questions concerning
the ability to take care of one’s daily needs are part of the
ROS. The personal and social history should include other
dimensions of functional capacity such as social, spiritual,
and economic resources; recreational activity; sleep pat-
terns; environmental control; and use of the healthcare
system. Maintaining function is a compelling concern of
older adults.

For all ages, a cognitive impairment that deprives the
patient of the ability to join in the decision-making process
emphasizes the need for a designated healthcare agent
(medical power of attorney for health care) and/or advance
directives (a document outlining the patient’s wishes
regarding extraordinary means of life support). Be aware
of the specific rules governing these issues in your state.
Encourage the patient and family to pursue these documents
if steps have not yet been taken.

The Frail. Frailty has its onset with the loss of physical
reserve and the increased risk for loss of physical function
and independence. Its prevalence increases with age,
particularly past 80 years. Frailty is characterized by weak-
ness, weight loss, low activity, and diminished ability to
respond to stress and is associated with adverse health
outcomes. It is considered an at-risk state caused by the
age-associated accumulation of deficits. With multisystem
dysregulation, decreased physiologic reserves, and increased
vulnerability to stressors, frailty shares features of normal
aging (Bandeen-Roche, et al, 2015). Nonetheless, age and
frailty are not necessarily synonymous.

Patients With Disabilities
You must adapt to the needs of all patients of any age
with disabling physical or emotional states (e.g., deafness,
blindness, depression, psychosis, developmental delays,
or neurologic impairments). They may or may not be
effective historians, but respect them regardless. Their
perspectives and attitudes matter. Involve each fully to the
limit of emotional and mental capacity or physical ability
(Fig. 1.4). Still, when necessary, use the family, other health
professionals involved in care, and the patient’s record
for collateral information. Some of the most common
communication barriers can be overcome by keeping the
following in mind:
• Family members are often available to make the patient

more comfortable and to provide information.
• Persons with impaired hearing often read, write, sign,

and/or read lips, but you must speak slowly and clearly
enunciate each word. A translator who signs may also
be used.

• Persons with visual impairment usually can hear, and
talking louder to make a point does not help. Remember
that you must always vocalize what you are trying to
communicate; gestures may not be seen.

forms. Ensure large print and ample lighting with a source
that does not glare or reflect in the eyes.

Some older adults may be confused or experience memory
loss, particularly for recent events. Take whatever extra time
is needed. Ask short (but not leading) questions, and keep
your language uncomplicated and free of double negatives.
Consult other family members to clarify discrepancies or
to fill in the gaps. On the other hand, older patients have a
lifetime of experience that may be a rich source of wisdom
and perspective. Listen for it.

The history is more complex and increasingly subtle
with the chronic, progressive, and debilitating problems
that occur with aging. Symptoms may be less dramatic,
vague or nonspecific. Confusion may be the only indication
of a major problem. Pain may be unreliably reported
because, with age, its perception varies. The excruciating
pain usually associated with pancreatitis, for example, may
be perceived as a dull ache, and myocardial infarction can
occur without any pain. Some patients may not report
symptoms because they attribute them to old age or because
they believe that nothing can be done. They may have lived
with a chronic condition for so long that it has been part
of their expectation of daily living.

From Appelbaum, 2007; Magauran, 2009; President’s Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioral Research, 1982.

BoX 1.14 Competency to Make Medical Decisions

Patients or their surrogates have the right to decide the extent of care
they will accept under your guidance. Many may have lost the ability
to make relevant competent decisions. To give informed consent,
patients must be well informed about what is proposed, and they
must be able to voluntarily give consent. Competency to make medical
decisions is used interchangeably with the word capacity. In a report
from the President’s Commission for the Study of Ethical Problems
in Medicine, clinical decision-making capacity includes three specific
elements: the patient has a set of values and goals, the patient is
able to understand and communicate information, and the patient is
able to reason and deliberate about the choice being made by the
patient. Competency may fluctuate from hour to hour or day to day,
depending on the age and the physical/emotional circumstance. It is
often necessary to seek consultative help in deciding a patient’s status.
The law in your state may require this, and it may ultimately be left
to a judge to decide on legal competence. It is important to recognize
that the patient who disagrees with you is not necessarily incompetent,
and the patient who agrees with you is not necessarily competent.

Patient safety

Multiple problems needing multiple medications increase risk for
iatrogenic disorders. A medication history with attention to interactions
of drugs, diseases, and aging is needed for prescribed and over-the-
counter medications and herbal preparations. It is particularly helpful
to have patients (of all ages) bring in their medication bottles. Encourage
patients with complex medication needs or several healthcare providers
to use a single pharmacy so that the computer database available to
the pharmacist can flag drug–drug interactions.

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CHAPTER 1 The History and Interviewing Process 21

FIg. 1.4 Interviewing a patient with a physical disability. Note the
uncluttered surroundings; be sure the patient in a wheelchair has room
to maneuver.

• Aging, debilitating illness, and frailty increase dependency
on others, worry about tomorrow, and grieving for what
has been lost. Recognize these concerns and the sense
of loss in both the patient and the caregivers. You can
acknowledge this and offer to talk about it.

The Next Step
Once the history (Box 1.15) has been built, move on to the
physical examination, the laying on of hands, which is
discussed in subsequent chapters. These chapters are

BoX 1.15 Types of Histories

A “complete” history is not always necessary. You may already know
the patient well and may be considering the same problem over time.
Therefore, adjust your approach to the need at the moment. There
are variations:
• The complete history makes you as thoroughly familiar with the

patient as possible. Most often, this history is recorded the first
time you see the patient.

• The inventory history is related to but does not replace the complete
history. It touches on the major points without going into detail. This
is useful when it is necessary to get a “feel” for the situation, and
the entire history taking will be completed in more than one session.

• The problem (or focused) history is taken when the problem is
acute, possibly life-threatening, requiring immediate attention so
that only the need of the moment is given full attention.

• The interim history is designed to chronicle events that have
occurred since your last meeting with the patient. Its substance
is determined by the nature of the problem and the need of the
moment. The interim history should always be complemented by
the patient’s previous record.

• Key information to gather regardless of the type of history includes
current medications and allergies.

segmented and are not meant to reflect the natural flow
that you will develop with experience. Do not be intimidated
because your patients expect you to be perfect. Just be
disciplined, alert, and recognize that your value judgments
are not necessarily imbued with wisdom.

FUNCTIoNAL AssEssMENT
Functional Assessment for All Patients
Quite simply, functional assessment is an attempt to understand a
patient’s ability to achieve the basic activities of daily living. This
assessment should be made for all older adults and for any person
limited by disease or disability, acute or chronic. A well-taken history
and a meticulous physical examination can bring out subtle influences,
such as tobacco and alcohol use, sedentary habits, poor food selection,
overuse of medications (prescribed and nonprescribed), and less than
obvious emotional distress. Even some physical limitations may not be
readily apparent (e.g., limitations of cognitive ability or of the senses).
Keep in mind that patients tend to overstate their abilities and, quite
often, to obscure reality.

When performing a functional assessment, consider a variety of
disabilities: physical, cognitive, psychologic, social, and sexual. An
individual’s social and spiritual support system must be as clearly
understood as the physical disabilities. There are a variety of physical
disabilities, including the following:
• Mobility

• Difficulty walking standard distances: 1
2 mile, 2 to 3 blocks, 1

3
block, across a room

• Difficulty climbing stairs, up and down
• Problems with balance

• Upper extremity function
• Difficulty grasping small objects, opening jars
• Difficulty reaching out or up overhead, such as taking something

off a shelf

• Household chores
• Heavy (vacuuming, scrubbing floors)
• Light (dusting)
• Meal preparation

• Activities of daily living
• Eating
• Toileting
• Selecting proper attire and putting on clothes
• Grooming and bathing
• Maintaining continence
• Walking and transferring (moving from bed to [wheel] chair, chair

to standing)
• Instrumental activities of daily living

• Shopping
• Medication management
• Money management
• Transportation (driving or navigating public transit)
• Preparing meals
• Using telephone and other communication devices
• Housework and basic home maintenance
Any limitations, even mild, in any of these areas will affect a patient’s

independence and autonomy and, to the extent of the limitation, increase
reliance on other people and on assistive devices. These limitations
indicate the loss of physical reserve and the potential loss of physical
function and independence that indicate the onset of frailty. The patient’s
social support system and material resources are then integral to the
development of reasonable management plans.

22

CHAPTER

2 Cultural Competency

Achieving cultural competence is a learning process that
requires self-awareness, reflective practice, and knowl-

edge of core cultural issues. It involves recognizing one’s
own culture, values, and biases and using effective patient-
centered communication skills. A culturally competent
healthcare provider adapts to the unique needs of patients
of backgrounds and cultures that differ from his or her
own. This adaptability, coupled with a genuine curiosity
about a patient’s beliefs and values, lay the foundation for
a trusting patient-provider relationship.

A Definition of Culture
Culture, in its broadest sense, reflects the whole of human
behavior, including ideas and attitudes, ways of relating to
one another, manners of speaking, and the material products
of physical effort, ingenuity, and imagination. Language is
a part of culture. So, too, are the abstract systems of belief,
etiquette, law, morals, entertainment, and education. Within
the cultural whole, different populations may exist in groups
and subgroups. Each group is identified by a particular
body of shared traits (e.g., a particular art, ethos, or belief;
or a particular behavioral pattern) and is rather dynamic
in its evolving accommodations with internal and external
influences. Any individual may belong to more than one
group or subgroup, such as ethnic origin, religion, gender,
sexual orientation, occupation, and profession.

Distinguishing Physical Characteristics
The use of physical characteristics (e.g., gender or skin
color) to distinguish a cultural group or subgroup is inap-
propriate. There is a significant difference between distin-
guishing cultural characteristics and distinguishing physical
characteristics. Do not confuse the physical with the cultural
or allow the physical to symbolize the cultural. To assume
homogeneity in the beliefs, attitudes, and behaviors of all
individuals in a particular group leads to misunderstandings
about the individual. The stereotype, a fixed image of any
group that denies the potential of originality or individuality
within the group, must be rejected. People can and do
respond differently to the same stimuli. Stereotyping occurs
through two cognitive phases. In the first phase, a stereotype
becomes activated when an individual is categorized into

a social group. When this occurs, the beliefs and feelings
(prejudices) come to mind about what members of that
particular group are like. Over time, this first phase occurs
without effort or awareness. In the second phase, people
use these activated beliefs and feelings when they interact
with the individual, even when they explicitly deny these
stereotypes. Multiple studies have shown that healthcare
providers activate these implicit stereotypes, or unconscious
biases, when communicating with and providing care to
minority patients (Stone and Moskowitz, 2011). With this
in mind, you can begin learning cultural competence by
acknowledging your implicit, or unconscious, biases toward
patients based on physical characteristics.

At the same time, this does not minimize the value of
understanding the cultural characteristics of groups, nor
does this deny the interdependence of the physical with
the cultural. Genotype, for example, precedes the develop-
ment of the intellect, sensitivity, and imagination that leads
to unique cultural achievements, such as the creation of
classical or jazz music. Similarly, a person’s phenotype,
like skin color, precedes most of the experience of life and
the subsequent interweaving of that phenotype with cultural
experience. Although commonly used in clinical practice,
the use of phenotypic traits to classify an individual’s race
is problematic. The term race has been used to categorize
individuals based on their continent or subcontinent of
origin (e.g., Asian, Southeast Asian). However, there is
ongoing debate about the usefulness of race, considering
the degree of phenotypic and genetic variation of individuals
from the same geographic region (Relethford, 2009). In
addition, the origins of race date back to the 17th century,
long before scientists identified genetic similarities. Over
time, beliefs about particular racial groups were shaped by
economic and political factors, and many believe race has
become a social construct (Harawa and Ford, 2009).

Genomics and Personalized Medicine
A growing body of research examines genetic markers
associated with racial and ethnic groups and potential
interactions with environmental determinants in predicting
disease susceptibility and response to medical treatment.
An explosion of genome-wide association studies (GWAS)
are attempting to link genomic loci, or single-nucleotide
polymorphisms (SNPs) with common diseases such as

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CHAPTER 2 Cultural Competency 23

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CHAPTER 2 Cultural Competency 23

with core aspects of the patient-centered care model (Fig.
2.1). Seeleman et al (2009) have proposed a framework for
teaching cultural competence that emphasizes an awareness
of the social context in which specific ethnic groups live.
For ethnic minority individuals, assessing the social context
includes inquiring about stressors and support networks,
sense of life control, and literacy. In doing so, healthcare
providers will need to be flexible and creative in working
with patients. Campinha-Bacote’s (2011) Process of Cultural
Competence Model is another approach and includes five
cultural constructs: encounters, desire, awareness, knowl-
edge, and skill. Box 2.1 defines these five constructs.

Cultural Humility
Cultural humility involves the ability to recognize one’s
limitations in knowledge and cultural perspective and be
open to new perspectives. Rather than assuming all patients
of a particular culture fit a certain stereotype, healthcare
providers should view patients as individuals. In doing so,
cultural humility helps equalize the imbalance in the
patient-provider relationship. (Borkan et al, 2008). A provider
may know many specific details about a patient’s particular
culture, yet not show cultural humility. Cultural humility
involves self-reflection and self-critique with the goal of
having a more balanced, mutually beneficial relationship.
It involves meeting patients “where they are” without
judgment to avoid the development of stereotypes. Attaining
cultural humility is an ongoing process shaped by every

rheumatoid arthritis, type 1 and type 2 diabetes mellitus,
and Crohn disease (Visscher et al, 2012). Personalized
medicine, as defined by the National Cancer Institute, is
“a form of healthcare that considers information about a
person’s genes, proteins and environment to prevent,
diagnose and treat disease” (Su, 2013). Direct-to-consumer
genetic testing is rapidly evolving and will likely become
more affordable and accessible to our patients. Healthcare
providers in all disciplines will need to become fluent in
the language of genomics and learn how to discuss risks
and benefits of gene testing with their patients and families
(Calzone et al, 2013; Demmer and Waggoner, 2014). With
this new emphasis, it will be perhaps even more important
to acknowledge unconscious biases and seek to understand
the patient’s unique cultural and personal health beliefs
and expectations.

Cultural Competence
Culturally competent care requires that healthcare providers
be sensitive to patient’s heritage, sexual orientation, socio-
economic situation, ethnicity, and cultural background
(Cuellar et al, 2008). Many models have been proposed to
teach cultural competence. Most include the domains of
acquiring knowledge (e.g., understanding the meaning
of culture), shaping attitudes (e.g., respecting differences
of individuals from other cultures), and developing skills
(e.g., eliciting patient’s cultural beliefs about health and
illness) (Saha et al, 2008). Some of these domains overlap

Patient-Centered Care
• Curbs hindering

behavior such as
technical language,
frequent interruptions,
or false reassurance

• Understands
transference/
countertransference

• Understands the stages
and functions of a
medical interview

• Attends to health
promotion/disease
prevention

• Attends to physical
comfort

Cultural Competence
• Understands the
meaning of culture
• Is knowledgeable
about different cultures
• Appreciates diversity
• Is aware of health

disparities and
discrimination affecting
minority groups

• Effectively uses
interpreter services
when needed

• Understands and is
interested in the patient as
unique person

• Uses a biopsychosocial model
• Explores and respects patient

beliefs, values, meaning of
illness, preferences, and needs

• Builds rapport and trust
• Finds common ground
• Is aware of own biases/

assumptions
• Maintains and is able to convey

unconditional positive regard
• Allows involvement of friends/

family when desired
• Provides information and

education tailored to patient’s
level of understanding

FIG. 2.1 Overlapping concepts of patient-centered care and cultural competence. (From Saha S et al,
2008.)

24 CHAPTER 2 Cultural Competency

24 CHAPTER 2 Cultural Competency
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healthcare professionals as well. Allopathic providers often
demonstrate skepticism regarding the use of complementary
and alternative medicine (CAM) without considering the
possibility of potential benefit to patients.

The Blurring of Cultural Distinctions
Some cultural differences may be malleable in a way that
physical characteristics are not. For example, one group of
people can be distinguished from another by language (see
Clinical Pearl, “Language Is Not All”). However, globaliza-
tion, the growing diversity of the U.S. population, and
evidence of healthcare disparities mandate more and more
that we learn one another’s languages. Although modern
technology and economics may eventually lead to universal-
ity in language, we can begin by acknowledging and

patient encounter that involves openness, partnership, and
genuine interest in understanding our patients’ belief
systems and lives (Fahlberg et al, 2016).

The Impact of Culture
The information in Box 2.2 suggests that racial and ethnic
differences, as well as social and economic conditions, may
affect the provision of specific healthcare services to certain
groups and subgroups in the United States. Poverty and
inadequate education disproportionately affect various
cultural groups (e.g., ethnic minorities and women);
socioeconomic disparities negatively affect the health and
medical care of individuals belonging to these groups.
Although death rates have declined overall in the United
States over the past 50 years, the poorly educated and those
in poverty still die at higher rates from the same conditions
than those who are better educated and economically
advantaged. Morbidity, too, is greater among the poor. Data
from the 2013 Centers for Disease Control and Prevention
(CDC) Health Disparities and Inequalities Report reveal a
variety of healthcare disparities. A significantly higher rate
of Hispanic and non-Hispanic blacks were uninsured
compared with Asian/Pacific Islanders and non-Hispanic
whites. The infant mortality rate among infants born to
non-Hispanic black women is more than double the rate
for infants born to non-Hispanic white women. Compared
with white women, a much higher percentage of black
women die from coronary heart disease before age 75 (37.9%
versus 19.4%). This same difference was observed between
black and white men (61.5% versus 41.5%) (CDC, 2013).
These rather stark facts are sufficient to underscore the
need for cultural awareness in health and medical care
professionals. Cultural and practice differences exist among

Data from Bukutu et al, 2008; Flores, 2010; Shao et al, 2016.

BoX 2.2 The Influence of Age, Race, Ethnicity,
Socioeconomic Status, and Culture

Age, gender, race, ethnic group, and, with these variables, cultural
attitudes, regional differences, and socioeconomic status influence
the way patients seek medical care and the way clinicians provide
care. Consider, for example, the ethnic and racial differences in the
treatment of depression in the United States. The prevalence of major
depressive disorders is similar across groups; however, compared
with white Americans, black and Latino patients are less likely to
receive treatment. Although some of the disparity is related to differing
patient attitudes and perceptions of counseling and medication, there
is growing evidence suggesting clinician communication style and
treatment recommendations differ on the basis of patient race and
ethnicity (Shao et al, 2016). Similarly, in the pediatric population,
black and Latino children in the United States also experience health
disparities, including lower overall health status and lower receipt of
routine medical care and dental care compared with white children.
Flores and colleagues (2010), in a systematic literature review,
demonstrated that, compared with white children, black children have
lower rates of preventive and population health care (e.g., breast-feeding
and immunization coverage), higher adolescent health risk behaviors
(e.g., sexually transmitted infections), higher rates of asthma emergency
visits, and lower mental health service use. There is a clear need to
better understand why these differences exist more globally, but
removing cultural blindness at the individual patient level is an important
first step.

Furthermore, the possible beneficial and harmful effects of many
culturally important herbal medicines, which are used but not always
acknowledged, must be understood and, in trusting relationships,
reported to us if we are to guide their appropriate use. Crossing the
cultural divide helps, but skepticism is a barrier. For example, many
allopathic medical providers question the notion that complementary
and alternative medicine might be a helpful adjuvant therapy for the
prevention and treatment of acute otitis media. However, in several
randomized controlled studies, xylitol, probiotics, herbal ear drops,
and homeopathic treatments have been shown, compared with placebo,
to have a greater effect in reducing pain duration and decreasing the
use of antibiotics. Although skepticism can be put aside, evidence-driven
guidance is still essential. Cultural competence is entirely consistent
with that.

From Campinha-Bacote, 2011.

BoX 2.1 Dimensions of Cultural Competence

CULTURAL ENCOUNTERS—The continuous process of interacting with
patients from culturally diverse backgrounds to validate, refine,
or modify existing values, beliefs, and practices about a cultural
group and to develop cultural desire, cultural awareness, cultural
skill, and cultural knowledge.

CULTURAL DESIRE—The motivation of the healthcare professional to
“want to” engage in the process of becoming culturally competent,
not “have to.”

CULTURAL AWARENESS—The deliberate self-examination and in-depth
exploration of one’s biases, stereotypes, prejudices, assumptions,
and “isms” that one holds about individuals and groups who are
different from them.

CULTURAL KNOWLEDGE—The process of seeking and obtaining a
sound educational base about culturally and ethnically diverse
groups.

CULTURAL SKILL—The ability to collect culturally relevant data
regarding the patient’s presenting problem, as well as accurately
performing a culturally based physical assessment in a culturally
sensitive manner.

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CHAPTER 2 Cultural Competency 25

Box 2.4 offers a guide to help understand the patient’s
beliefs and practices that can lead to individualized, culturally
competent care. Particular attention should be paid to caring
for patients who self-identify as being lesbian, gay, bisexual,
and transgender (LGBT). Unfortunately, these individuals
face discrimination and disrespect in the healthcare setting.
Thus, it is imperative that healthcare providers invest time
in becoming culturally competent and develop cultural
humility to work effectively with LGBT patients. Specific
responsibilities include providing a welcoming and safe
environment, gathering a history with sensitivity and
compassion, and performing a physical examination using
a “gender-affirming” approach (i.e., using the correct name
and pronouns). Box 2.5 provides useful terminology (Center
for Excellence for Transgender Health, 2016).

Interprofessional Care—A Culture Shift in the
Health Professions
There is a harmony—a unity—in the care of patients that
is not constricted by the cultural and administrative boundar-
ies of the individual health professions. To the extent that
we stake out territories of care by allowing individual profes-
sional cultures and needs to take precedence over patient
needs, we may impede the achievement of harmony. In
2010, the World Health Organization (WHO) published

overcoming our individual biases and cultural stereotypes.
Because it is impossible to learn the native languages of
all of our patients, when language barriers arise, we must
become aware of our resources and know how to effectively
use interpreters (Seeleman et al, 2009). Use of medical
interpreters has a positive impact on healthcare quality,
but we continue to use suboptimal methods of communica-
tion (e.g., family members). Although greater adoption of
medical interpreter use involves policy and system-level
changes, healthcare provider training and encouragement
remain critically important (DeCamp et al, 2013).

ClInICal pearl

Language Is Not All
A patient who knows the English language, however well, cannot be
assumed to know the culture. Consider the diversity of the populations
in Britain, India, American Samoa, and South Africa who are English
speaking. The absence of a language barrier does not preclude a
cultural barrier. You will likely still need to achieve a “cultural
translation.”

The Primacy of the Individual in Health Care
The individual patient may be visualized at the center of
an indefinite number of concentric circles. The outermost
circles represent constraining universal experiences (e.g.,
death). The circles closest to the center represent the various
cultural groups or subgroups to which anyone must, of
necessity, belong. The constancy of change forces adaptation
and acculturation. The circles are constantly interweaving
and overlapping. For example, a common experience in
the United States has been the economic gain at the root
of the assimilation of many ethnic groups. Although this
results in greater homogeneity among the population, an
individual’s gender, ethnic behaviors, or sexual orientation
and identity will likely be unique. Predicting the individual’s
character merely on the basis of the common cultural
behavior, or stereotype, is not appropriate. Based on the
Joint Commission 2010 report, “Checklist to Improve
Effective Communication, Cultural Competence, and
Patient- and Family-Centered Care Across the Care Con-
tinuum,” White and Stubblefield-Tave (2016) remind us
that unconscious bias, stereotyping, racism, gender bias,
and limited English proficiency underlie healthcare inequali-
ties. They offer their own checklist of recommendations
for healthcare providers to address these issues with the
goal of reducing disparities in care (Box 2.3).

Ethical issues often arise when the care of an individual
comes into conflict with the utilitarian needs of the larger
community, particularly with the recognition of limited
resources and, in the United States, rising healthcare costs.
Cultural attitudes of our patients, at times vague and poorly
understood, may constrain our professional behavior
and confuse the context in which we serve the individual.

Modified from White & Stubblefield-Tave, 2016.

BoX 2.3 Provider Role in Reducing Disparities in
Health Care

This modified “culturally competent checklist” is provided as a guide
to help providers partner with patients and families to provide high-
quality care. Although some items are simple, others are quite
complicated and difficult to achieve. On our path to achieving cultural
humility, we should strive to incorporate as many of these recom-
mendations as possible into our routine clinical practice.

1. Humanize your patient.
2. Identify and monitor conscious and unconscious biases.
3. Do a teach-back.
4. Help the patient to learn about his or her disease or condition.
5. Welcome a patient’s friend, partner, and/or family members.
6. Learn a few key words and phrases in the most common languages

in your area.
7. Use a qualified medical interpreter as appropriate.
8. Be aware of the potential for “false fluency” (clinician language

skill should be tested and certified).
9. Seek training in working with an interpreter.

10. Consider the health literacy of one’s patients.
11. Respond thoughtfully to patient complaints.
12. Hold one’s institutions accountable for providing culturally and

linguistically competent care.
13. Advocate that the affiliated institution’s analyses of patient satisfac-

tion and outcome include cultural group data and that the results
lead to concrete action.

14. Encourage patients to complete patient satisfaction and demo-
graphics forms.

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“The Framework for Action on Interprofessional Education
and Collaborative Practice.” In this publication, interprofes-
sional education is described as training in which “students
from two or more professions learn about, from and with
each other to enable effective collaboration and improve
health outcomes.” The WHO believes this type of training
can lead to “interprofessional collaborative practice,” in
which health team members from different professional
backgrounds work together to deliver high-quality care. In
recent years, there has been a surge in published curricula
on interprofessional education and team-based training
for students and faculty. Although most curricula for nursing
and medical students focus on improving communication
skills, training programs need to evolve to address cultural
humility and valuing diversity in patient populations
(Foronda et al, 2016).

The Impact of Culture on Illness
Disease is shaped by illness, and illness—the full expression
of the impact of disease on the patient—is shaped by the

Modified from Stulc, 1991.

BoX 2.4 Cultural Assessment Guide: The Many Aspects of Understanding

Health Beliefs and Practices
• How does the patient define health and illness? How are feelings

concerning pain, illness in general, or death expressed?
• Are there particular methods used to help maintain health, such as

hygiene and self-care practices?
• Are there particular methods being used for treatment of illness?
• What is the attitude toward preventive health measures such as

immunizations?
• Are there health topics that the patient may be particularly sensitive

to or consider taboo?
• Are there restrictions imposed by modesty that must be respected;

for example, are there constraints related to exposure of parts of
the body, discussion of sexual health, and attitudes toward various
procedures such as termination of pregnancy or vasectomy?

• What are the attitudes toward mental illness, pain, chronic disease,
death, and dying? Are there constraints in the way these issues are
discussed with the patient or with reference to relatives and friends?

• Is there a person in the family responsible for various health-related
decisions such as where to go, whom to see, and what advice to
follow?

• Does the patient prefer a health professional of the same gender,
age, and ethnic and racial background?

Faith-Based Influences and Special Rituals
• Is there a religion or faith to which the patient adheres?
• Is there a significant person to whom the patient looks for guidance

and support?
• Are there any faith-based special practices or beliefs that may affect

health care when the patient is ill or dying?

Language and Communication
• What language is spoken in the home?
• How well does the patient understand English, both spoken and

written?

• Are there special signs of demonstrating respect or disrespect?
• Is touch involved in communication?
• Is an interpreter needed? (If so, this person ideally should be a

trained professional and not a family member.)

Parenting Styles and Role of Family
• Who makes the decisions in the family?
• What is the composition of the family? How many generations are

considered to be a single family, and which relatives compose the
family unit?

• What is the role of and attitude toward children in the family?
• Do family members demonstrate physical affection toward their

children and each other?
• Are there special beliefs and practices surrounding conception,

pregnancy, childbirth, lactation, and childrearing? Is co-sleeping
practiced? (If so, further inquiry is necessary regarding safe sleep
practices for infants 12 months and younger.)

Sources of Support Beyond the Family
• Are there ethnic or cultural organizations that may have an influence

on the patient’s approach to health care?
• Are there individuals in the patient’s social network that can influence

perception of health and illness?
• Is there a particular cultural group with which the patient identifies?

Can this be clarified by where the patient was born and has lived?

Dietary Practices
• Who is responsible for food preparation?
• Are any foods forbidden by the culture, or are some foods a cultural

requirement in observance of a rite or ceremony?
• How is food prepared and consumed?
• Are there specific beliefs or preferences concerning food, such as

those believed to cause or to cure an illness?
• Are there periods of required fasting? What are they?

From Center for Excellence for Transgender Health, 2016.

BoX 2.5 Gender, Transgender, and Sexuality
Terminology

Gender/gender identity: People’s internal sense of self and how they
fit into the world from the perspective of gender.

Sex: Historically referred to the sex assigned at birth, based on external
genitalia; often used interchangeably with gender, although there
are differences, especially when considering the transgender
population.

Transgender: Person whose gender identity differs from sex assigned
at birth; a transgender man is someone with a male gender identity
and a female birth assigned sex; a transgender woman is someone
with a female gender identity and a male birth assigned sex.

Gender nonconforming: Person whose gender identity differs from
that sex assigned at birth but may be more complex, fluid, less
clearly defined than a transgender person.

They/Them/Their: Neutral pronouns used by some who have noncon-
forming gender identity.

Sexual orientation: Term describing a person’s sexual attraction; sexual
orientation of transgender people should be defined by the
individual.

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CHAPTER 2 Cultural Competency 27

In Japan, for example, the family is generally considered
the legitimate decision-making authority for competent and
incompetent patients. Persons of some cultures (e.g., Middle
Eastern and Navajo Native American) believe that a patient
should not be told of a diagnosis of a metastatic cancer or
a terminal prognosis for any reason, but this attitude is
not likely to be shared by Americans with European or
African traditions. Traditionally, the members of the Navajo
culture believe that thought and language have the power
to shape reality. Talking about a possible outcome is thought
to ensure the outcome. It is important, then, to avoid
thinking or speaking in a negative way. The situation can
be dealt with by talking in terms of a third person or an
abstract possibility. You might even refer to an experience
you have had in your own family. Obviously, the conflicts
that may arise from differing views of autonomy, religion,
and information sharing require an effort that is dominated
by a clear understanding of the patient’s goals. However,
it is important to remember that a patient may not typify
the attitudes of the group of origin.

Modes of Communication
Communication and culture are interrelated, particularly
in the way feelings are expressed verbally and nonverbally.
The same word may have different meanings for different
people. For example, in the United States, a “practicing
physician” is an experienced, trained person. “Practicing,”
however, suggests inexperience and the status of a student
to an Alaskan Native or to some Western Europeans.
Similarly, touch, facial expressions, eye movement, and
body posture all have varying significance.

In the United States, for example, people may tend to
talk more loudly and to worry less about being overheard
than others do. The English, on the other hand, tend to
worry more about being overheard and speak in modulated
voices. In the United States, people may be direct in
conversation and eager to be thought logical, preferring to
avoid the subjective and to come to the point quickly. The
Japanese tend to do the opposite, using indirection, talking
around points, and emphasizing attitudes and feelings.
Silence, although sometimes uncomfortable for many of
us, affords patients who are Native American time to think;
the response should not be forced and the quiet time should
be allowed.

Many groups use firm eye contact. The Spanish meet
one another’s eyes and look for the impact of what is being
said. The French, too, have a firm gaze and often stare
openly at others. This, however, might be thought rude or
immodest in some Asian or Middle Eastern cultures.
Americans are more apt to let the eyes wander and to grunt,
nod the head, or say, “I see,” or “uh huh,” to indicate
understanding. Americans also tend to avoid touch and
are less apt to pat you on the arm in a reassuring way than
are, for example, Italians.

These are but a few examples of cultural variation in
communication. They do, however, suggest a variety of
behaviors within groups. As with any example we might

totality of the patient’s experience. Cancer is a disease. The
patient dealing with, reacting to, and trying to live with
cancer is having an illness—is “ill” or “sick.” The definition
of “ill” or “sick” is based on the individual’s belief system
and is determined in large part by his or her enculturation.
This is so for a brief, essentially mild episode or for a
chronic, debilitating, life-altering condition. If we do not
consider the substance of illness—the biologic, emotional,
and cultural aspects—we will too often fail to offer complete
care. To make the point, imagine that while taking a shower
you have conducted a self-examination and, still young,
still looking ahead to your career, you have discovered an
unexpected mass in a breast or a testicle. How will you
respond? How might other individuals respond?

evidence-Based practice in physical examination

Cultural Adaptations for Screening
We often use a variety of screening tools to identify health concerns
and help our patients stay well. These screening tools are based on
norms that may not be consistent across cultures. Screening tools
may contain cultural biases and result in misleading information.
Whenever possible, we should use instruments that have been adapted
for and tested with individuals from our patients’ specific cultural
groups. Screening, brief intervention, and referral to treatment (SBIRT)
is an approach to identify and care for patients affected by alcohol
and drug use. Using SBIRT involves the use of validated screening
tools. Fortunately, a recent literature review indicates a variety of
instruments have been validated in racial and ethnic subgroups (Manuel
et al, 2015). Before implementing a screening tool, it is our responsibility
to ensure the instrument is valid and at an appropriate literacy level
for our specific patient populations.

The Components of a Cultural Response
When cultural differences exist, be certain that you fully
understand what the patient means and know exactly what
he or she thinks you mean in words and actions. Asking
the patient if you are unsure demonstrates curiosity and
is far better than making an assumption, which could result
in a damaging mistake. Avoid assumptions about cultural
beliefs and behaviors made without validation from the
patient.

Beliefs and behaviors that will have an impact on patient
assessment include the following:
• Modes of communication: the use of speech, body

language, and space
• Health beliefs and practices that may vary from your

own or those of other patients you care for
• Diet and nutritional practices
• The nature of relationships within a family and

community
A variety of ethnic attitudes toward autonomy may exist.

The patient-centered care model, still firmly respected in
the United States, could be at odds with a more family-
centered model that is more likely dominant elsewhere.

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be comfortable with Western approaches to health and
medical care. However, the scientific view is reductionist
and looks to a very narrow, specific cause and effect. A
more naturalistic or “holistic” approach broadens the context.
It views our lives as part of a much greater whole (the
entire cosmos) that must be in harmony. If the balance is
disturbed, illness can result. The goal, then, is to achieve
balance and harmony. Aspects of this concept are evident
among the beliefs of many Hispanics, Native Americans,
Asians, and Middle Eastern groups, and they are increasingly
evident in people of all ethnic groups in the United States
today (Box 2.6). Other groups believe in the supernatural
or forces of good and evil that determine individual fate.
In such a context, illness may be thought of as a punishment
for wrongdoing.

Clearly, there can be a confusing ambivalence in many
of us, patient and healthcare provider alike, because our
genuine faith-based or naturalistic beliefs may conflict with
the options available for the treatment of illness. Consider,
for example, a child with a broken bone, the result of an
unintentional injury that occurred while the child was under
the supervision of a babysitter. The first need is to tend
to the fracture. That done, there is a need to talk with
the parents about the guilt they may feel because they
were away working. They might think this injury must
be God’s punishment. It is important to be aware of, to
respect, and to discuss without belittlement a belief that
may vary from yours in a manner that may still allow you
to offer your point of view. This can apply to the guilt of
a parent and to the use of herbs, rituals, and religious
artifacts. After all, the pharmacopoeia of Western medicine
is replete with plants and herbs that we now call drugs (see
Clinical Pearl, “Complementary and Alternative Treatments
for the Common Cold”). Our difficulty in understanding
the belief of another does not invalidate its substance, nor
does a patient’s adherence to a particular belief preclude
concurrent reliance on allopathic or osteopathic health
practitioners.

use, they are not to be thought of as rigidly characteristic
of the indicated groups. Still, the questions suggested
in Box 2.4 can at times provide insight to particular
situations and can help avoid misunderstanding and
miscommunication.

The cultural and physical characteristics of both patient
and healthcare provider may significantly influence com-
munication (Fig. 2.2). Social class, race, age, and gender
are variables that characterize everyone; they can intrude
on successful communication if there is no effort for mutual
knowledge and understanding (see Clinical Pearl, “The
Impact of Gender”). The young student or healthcare
provider and the older adult patient may have to work harder
to develop a meaningful relationship. Recognizing these
differences and talking about them, evoking feelings sooner
rather than later, can result in a more positive encounter
for both patient and provider. It is permissible to ask whether
the patient is uncomfortable with you or your background
and whether they are willing to talk about it.

FIG. 2.2 Being sensitive to cultural differences that may exist between
you and the patient can help avoid miscommunication.

ClInICal pearl

The Impact of Gender
In a qualitative study examining videotapes of primary care visits,
compared with male physicians, female physicians were more “patient-
centered” in their communication skills. The greatest amount of
patient-centeredness was observed when female physicians interacted
with female patients. Elderly hospitalized patients treated by female
internists had lower mortality and readmissions compared with those
cared for by male internists. On the flip side, compared with a female
physician, obese men seen by a male physician were more likely to
receive diet and exercise counseling.

From Bertakis and Azari, 2012; Pickett-Blakely et al, 2011; Tsugawa et al, 2017.

Health Beliefs and Practices
The patient may have a view of health and illness and an
approach to cure that are shaped by a particular cultural
and/or faith belief or paradigm. If that view is “scientific,”
in the sense that a cause can be determined for every
problem in a very precise way, the patient is more apt to

ClInICal pearl

Complementary and Alternative Treatments for the
Common Cold
Home-based remedies for common colds are widely used. In children,
the following therapies may be effective: buckwheat honey, vapor rub,
geranium, and zinc sulfate. In adults, Echinacea purpurea, geranium
extract, and zinc gluconate may be effective. When asking about
medications, always remember to ask about use of complementary
and alternative therapies. Using a nonjudgmental approach, you may
wish to start with the question, “What else have you tried?”

From Fashner et al, 2012.

Family Relationships
Family structure and the social organizations to which a
patient belongs (e.g., faith-based organizations, clubs, and

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One type of already-known behavior may predict another
type of behavior. For example, low-income urban mothers
who take advantage of appropriate prenatal care generally
take advantage of appropriate infant care, regardless of
educational level (Van Berckelaer et al, 2011). Adolescents
who are not monitored by their parents are more likely to
smoke, use alcohol and marijuana, be depressed, and initiate
sexual activity than are those who are monitored (Dittus
et al, 2015; Pesola et al, 2015). Being aware of this sequence
of related behaviors is especially important because it may
be unrelated to the integrity of the family structure, gender,
or background. Parenting style and childrearing practices
such as setting boundaries and expectations may be cultur-
ally driven. Many adolescents and young adults find comfort
in their families’ cultural traditions and practices and benefit
from their connectedness. In a large study of U.S. college
students from immigrant families, compared with their
peers, students who retained their heritage practices reported
fewer health risk behaviors such as substance use, unsafe
sex, and impaired driving (Schwartz et al, 2011). These
examples remind us that one individual may belong to
many subgroups and that the behaviors and attitudes of a
subgroup—for example, a young man who remains con-
nected to his cultural heritage—can override the impact
of the cultural values of the larger group (e.g., youth whose
peers are engaged in risk-taking behaviors).

Diet and Nutritional Practices
Beliefs and practices related to food, as well as the social
significance of food, play an obvious vital role in everyday
life. Some of these beliefs of cultural and/or faith-based
significance may have an impact on the care you provide
to patients. An Orthodox Jewish patient will not take some
medicines, particularly during a holiday period like Passover,
because the preparation of a drug does not meet the religious
rules for food during that time. A patient who is Muslim
must respect Halal (prescribed diet), even throughout
pregnancy. A Chinese person with hypertension and a
salt-restricted diet may need to consider a limited use of
monosodium glutamate (MSG) and soy sauce. Attitudes
toward vitamins vary greatly, with or without scientific proof,
in many of the subgroups in the United States. It is still
possible to work out a mutually agreed-on management
plan if the issues are recognized and freely discussed. This
is also possible with attitudes toward home, herbal, and
natural—complementary or alternative—therapies. Many
will have benefit; others may be dangerous. For example,
some herbal medications containing cassia senna may cause
liver damage, and other herbal preparations interact with
prescribed medications (Posadzki et al, 2013).

Summing Up
As healthcare providers, we face a compelling need to meet
each patient on his or her own terms and to resist forming
a sense of the patient based on prior knowledge of the race,
religion, gender, ethnicity, sexual identity and orientation, or

schools) are among the many imprinting and constraining
cultural forces. The expectations of children and how they
grow and develop are key in this regard and often culturally
distinct. Determining these family and social structures
needs emphasis in the United States today, with its shift
toward dual-income families, single-parent families, and
a significant number of teenage parents. The prevalence
of divorce (nearly one for every two marriages) and the
increasing involvement of both parents in child care in
two-parent families suggest cultural shifts that need to be
recognized.

Modified from Purnell, 2013.

BoX 2.6 The Balance of Life: The “Hot” and
the “Cold”

A naturalistic or holistic approach often assumes that there are external
factors—some good, some bad—that must be kept in balance if we
are to remain well. The balance of “hot” and “cold” is a part of the
belief system in many cultural groups (e.g., Middle Eastern, Asian,
Southeast Asian, and Hispanic). To restore a disturbed balance, that
is, to treat, requires the use of opposites (e.g., a “hot” remedy for a
“cold” problem and vice versa). Different cultures may define “hot”
and “cold” differently. It is not a matter of temperature, and the words
used might vary: for example, the Chinese have named the forces
yin (cold) and yang (hot). The bottom line: We cannot ignore the natu-
ralistic view if many of our patients are to have appropriate care.

Hot and Cold Conditions and Their Corresponding Treatments

COLD
CONDITIONS

HOT
TREATMENTS

HOT
CONDITIONS

COLD
TREATMENTS

CONDITIONS FOODS CONDITIONS FOODS

Cancer
Cold
Earaches
Headaches
Joint pain
Malaria
Menses
Pneumonia
Stomach

cramps
Teething
Tuberculosis

Beef
Cereals
Chili peppers
Chocolate
Eggs
Goat’s milk
Liquor
Onions
Peas

Constipation
Diarrhea
Fever
Infection
Kidney

problems
Rash
Sore throat

Barley water
Chicken
Dairy products
Fresh vegetables
Fruits
Honey
Goat meat
Raisins

MEDICINES
AND HERBS

MEDICINES AND
HERBS

Anise
Aspirin
Castor oil
Cinnamon
Cod liver oil
Garlic
Ginger root
Iron
Tobacco
Penicillin
Vitamins

Bicarbonate of
soda

Milk of Magnesia
Orange flower

water
Sage

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patients and display genuine curiosity about their beliefs
and values, you will be making strides toward cultural
competence. The U.S. Department of Health and Human
Services Office of Minority Health provides continuing
education, resources, and tools through the “Think Cultural
Health” initiative (https://www.thinkculturalhealth.hhs.gov).
The RESPECT model is one useful tool to bridge the
cultural divide between patients and healthcare providers
(Fig. 2.3).

It is not unusual to find tables of information about
healthcare–related cultural attitudes for a variety of religious
and ethnic groups in reference materials. Although this
provides quick access to information about various

culture(s) from which that patient comes. That knowledge
should not be formative in arriving at conclusions; rather,
we must draw on it to help make the questions we ask
more constructively probing to avoid viewing the patient as
a stereotype (Box 2.7). You need to understand yourself well.
Your involvement with any patient gives that interaction a
unique quality, and your contribution to that interaction,
to some extent, makes it different from what it might have
been with anyone else. Remember that your attitudes and
prejudices, which are largely culturally derived, may interfere
with your understanding of the patient and increase the
probability of unconscious bias and stereotypic judgment.
When you’re able to adapt to the unique needs of your

BoX 2.7 Communication

This list of questions, derived over the years from our experience and
multiple resources, illustrates the variation in human responses. Try not
to be intimidated by the mass of “need to know” cultural issues, but
begin reflecting on them as you work with patients to raise your cultural
awareness and develop a greater sense of cultural humility.
• How important are nonverbal clues?
• Are moments of silence valued?
• Is touching to be avoided?
• Are handshakes, or even embracing, avoided or desired at meeting

and parting?
• What is the attitude toward eye contact?
• Is there a greater than expected need for “personal space”?
• What is the verbal or nonverbal response if your suggestions are

not understood?
• Is there candor in admitting lack of understanding?
• What are the attitudes concerning respect for self and for authority

figures?
• What are the attitudes toward persons in other groups, such as

minorities, majorities?
• What are the language preferences?
• What is the need for “chit-chat” before getting down to the primary

concern?
• Is there a relaxed or rigid sense of time?
• What is the degree of trust of healthcare professionals?
• How easily are personal matters discussed?
• Is there, even with you, a wish to avoid discussing income and other

family affairs?

Health Customs/Health Practices
• What is the degree of dependence on the healthcare system, for

illness alone or also for preventive and health maintenance needs?
• What is generally expected of a health professional and what defines

a “good one?”
• What defines health?
• Are there particularly common folk practices?
• Is there a greater (or lesser) inclination to invoke self-care and use

home remedies?
• Is there a particular suspicion or fear of hospitals?
• What is the tendency to use alternative care approaches and/or

herbal remedies exclusively or as a complement?
• What are the tendencies to invoke the magical or metaphysical?
• Who is ultimately responsible for outcomes, you or the patient?

• Who is ultimately responsible for maintaining health, you or the
patient?

• Is there a particular fear of painful or intrusive testing?
• Is there a tendency toward stoicism?
• What is the dependence on prayer?
• Is illness thought of as punishment and a means of penance?
• Is there “shame” attached to illness?
• What is the belief about the origins of illness?
• Is illness thought to be preventable and, if so, how?
• What is the attitude toward autopsy?
• Does a belief in reincarnation mandate that the body be left intact?
• Are there particular cultural cooking habits that can influence diagnosis

or management?
• Is the degree of modesty in both men and women more than you

would generally expect?
• Do women, considering modesty, need a much more cautious and

protected approach than usual—for example, during the
examination?

Family, Friends, and the Workplace
• How tightly organized (and multigenerational) is the family

hierarchy?
• How tight is the family?
• Is social life extended beyond the family and, if so, to what degree?
• Does the family tend to be matriarchal or patriarchal?
• What are the relative roles of women and men?
• Are there particular tasks assigned to individual genders—for example,

who does the laundry, family finances, grocery shopping?
• To what extent are older adults and other authority figures given

deference, and how?
• Who makes decisions for the family?
• To what extent is power shared?
• Who makes decisions for the children and adolescents?
• How strongly are children valued?
• Is there a greater value placed on one of the genders?
• How much are self-reliance and personal discipline valued?
• What is the work ethic?
• What is the sense of obligation to the community?
• How is education sought, that is, from school, reading, and/or

experience?
• What is the emphasis on tradition and ritual practice?

CHAPTER 2 Cultural Competency 31

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CHAPTER 2 Cultural Competency 31

to meet your patients. Patient by patient, your insights will
develop as you avoid stereotypes, consider the individual,
and become increasingly culturally competent. View cultural
competence as a lifelong journey and not a destination or
endpoint in and of itself.

population groups, our experience suggests that the rigid
superficiality in this information often does not adequately
describe the beliefs and attitudes of a particular individual.
Our purpose in this chapter is to review many of the ques-
tions and frameworks that might be relevant as you prepare

Guide to Providing Effective Communication and Language Assistance Services
www.ThinkCulturalHealth.hhs.gov

The RESPECT Model

What is most important in considering the effectiveness of your cross-cultural communication,
whether it is verbal, nonverbal, or written, is that you remain open and maintain a sense of
respect for your patients. The RESPECT Model1 can help you remain effective and patient-
centered in all of your communication with patients.

apport
• Connect on a social level
• See the patient’s point of view
• Consciously suspend judgment

Recognize and avoid making assumptions

mpathy
• Remember the patient has come to you for help
• Seek out and understand the patient’s rationale for his/her behaviors and

illness
• Verbally acknowledge and legitimize the patient’s feelings

upport
• Ask about and understand the barriers to care and compliance
• Help the patient overcome barriers; Involve family members if appropriate
• Reassure the patient you are and will be available to help

artnership
• Be flexible
• Negotiate roles when necessary
• Stress that you are working together to address health problems

xplanations
• Check often for understanding
• Use verbal clarification techniques

ultural

competence

• Respect the patient’s cultural beliefs
• Understand that the patient’s views of you may be defined by ethnic and

cultural stereotypes
• Be aware of your own cultural biases and preconceptions
• Know your limitations in addressing health issues across cultures
• Understand your personal style and recognize when it may not be working

with a given patient

rust
• Recognize that self-disclosure may be difficult for some patients; Consciously

work to establish trust

FIG. 2.3 The RESPECT Model.