chapter 1 Family Interviewing and History-Taking
Most textbooks deal with the history-taking family interview as a diagnostic procedure—a systematic data-gathering exercise designed to identify problems and lead to a diagnostic formulation and, ultimately, a treatment plan. Notwithstanding the incredible advances in diagnostic technology, it is well documented that the diagnostic yield of a good history vastly exceeds that of the physical examination and all available diagnostic technologies combined, which makes it surprising that more time is not spent teaching and honing interviewing skills. To achieve its maximum value, however, the family interview should be as much a therapeutic as a diagnostic procedure. Treatment begins as the family walks in the door.
What Do Families Want?
Whenever I have asked parents to identify the most important qualities they seek in a physician, their answers have been stunningly consistent. You might imagine that their first priority would be professional competence, but this quality is rarely, if ever, mentioned. Their first wish is usually for “a doctor who gives us enough time.” Some physicians are able to leave families satisfied that they have given them enough time, even when they have had a relatively short visit. Other physicians who have relatively lengthy visits with families may nonetheless leave them feeling dissatisfied because these physicians permit frequent interruptions or distractions, interrupt the parents, do not maintain eye contact, are not attentive listeners, or because they have failed to identify and deal with the real reason for the visit, such as parents’ unspoken fears (see the section later in this chapter on “Uncovering Hidden Agendas”). Such transgressions can markedly reduce family satisfaction.
The second physician quality sought most often by parents is described in their wish for “a doctor who explains things to me in words I can understand.” When parents have expressed this wish, I have often asked if they have ever had a doctor who explained their child’s problem to them in words they did not understand. Their answer is often affirmative, and if I then ask them why they did not interrupt and ask for clarification, a typical response is, “I was afraid he/she would think I was stupid.”
You can learn a lot by eavesdropping on conversations between other health professionals and patients’ families. Check the body language: Who is sitting? Who is standing? Who is lying in bed? When a physician is standing and conversing with patients or family members, the latter are often visibly anxious. If it were possible to legislate changes in body language, the first law to be enacted would require everyone involved in such conversations to sit down. Being seated does not prolong conversations. However, the mere act of sitting down, even for a few moments, conveys a powerful message to the patient or family. It says unmistakably, “I have time to listen to you and to talk to you.”
Next, listen to the health professional’s vocabulary. Remember that the second priority mentioned by most parents is to have a physician who explains things to them in language that they understand. Communication skills—that is, good listening and clear talking (and mostly the listening)—count for more than anything else with parents. In your conversations with them, use lay terms whenever possible, avoiding jargon and (to them) unintelligible alphabetical abbreviations, such as ECG, EEG, BUN, ICU, CT, and MRI. Also, try to avoid using words such as pulmonary, renal, cardiac, allergy, and a hundred others that may mean little or nothing to many parents and can strike terror into the hearts of some people. Terms such as pneumonia, meningitis, epilepsy, asthma, and mental retardation can have very different meanings for parents than they do for you. Use such terms sparingly and only after finding out exactly what they mean to the parents.
The qualities that most parents seek in their physicians tell us a lot about our job definition. The late Dr. Harry Gordon, a distinguished pediatrician, put it neatly: “The physician’s mission is to relieve anxiety—and all our knowledge, research, diagnosis, and treatments are only means to that end.” This concept underlines the importance of differentiating between disease (the pathologic condition) and illness (how the patient feels). Diagnosis and treatment of the two are not identical, and treatment of both conditions is essential to successful management.
It has been documented that, as students advance through undergraduate and postgraduate years, two unfortunate changes tend to develop in the content of their patient interviews: They tend to focus progressively more on disease and less on illness. They also tend to season their conversation with fewer expressions of empathy.
Finding out how the child and family feel and expressing your appreciation of their feelings can be highly therapeutic. Do not hesitate to season your comments with regular expressions of empathy and support, such as:
Such expressions help lay the foundation for successful management plans in dealing with a child’s problems.
Empathy alone is certainly no substitute for scientific knowledge or for first-class clinical diagnosis and treatment skills. However, empathy also should not be regarded as some form of “warm and fuzzy” bedside manner, whose principal features are a gentle touch and a velvet voice. Empathy involves expressing genuine insight into how patients and families feel and an appreciation of the difficulties they face.
Interviewing and History-Taking Skills
Two clinical skills—interviewing and history-taking— deserve practice and polish more than others because the more highly developed the interviewer’s skills, the more benefit accrues to patients and their families. Like any good productive conversation, a successful medical interview incorporates the following components:
Style of dress: does it matter?
During the past several decades, health professionals have tended to dress more and more informally, often to the point that it is progressively harder for patients, their families, and sometimes even colleagues to identify who they are and what they do. Years ago, many pediatric health care practitioners abandoned the practice of wearing white coats, based on a totally untested belief that white coats frightened children. In fact, in experimental situations in which children have been shown photographs of physicians in different types of dress and asked to rate who they would trust most or who was the most competent, children have almost always gravitated toward those most traditionally attired (e.g., wearing a white coat). For families from cultures other than our own (which includes an increasing proportion of many communities), nontraditional dress among health care professionals may even be disconcerting. The prime consideration in choosing your attire should be what will make your patients feel most comfortable.
In addition to no longer wearing identifiable attire, many health care professionals no longer wear a legible identifying badge stating their name and occupation, which suggests that they may not want their patients and their patients’ families to remember who they are or what they do. However, our patients and their families deserve clearly printed information that tells them who we are, what we do, and how we can be contacted.
Greetings
Going to the waiting area to greet every outpatient and family you see and escorting them to the interview/examination room is a valuable and much appreciated practice. This simple gesture sets the right tone. It also offers a great opportunity to begin making friends with the child and to gain a first impression of how family members interact (in body language as well as conversation). Most children older than 1 year (even the shy, clingy ones) can be persuaded to give you a “high five”—a gesture that often elicits a smile as well. Meeting older children in a waiting area gives you the chance to offer them a compliment, such as on an article of clothing. These overtures can be great icebreakers.
In many cultures it is considered thoroughly rude to “get down to business” right away, whether the business is commerce or health care. Common courtesy demands some pleasant preliminary banter, for example, regarding the weather or the family. We can learn a lot from such traditions, which help put people at ease.
Terms of address
In verbal and written communications, always try to refer to the child by name (not as “he” or “she”). Similarly, referring to a youngster as a “well-developed, well-nourished, 2-year-old Caucasian female” robs the child of all individuality and extinguishes any traces of empathy. Compare this statement with, “Mary Anne is a healthy looking, vivacious, 2-year-old, red-headed girl,” which instantly communicates Mary Anne’s individuality, as well as your respect.
With children older than 1 year, it is a good practice to greet the child first, then the parents. This simple gesture makes it clear where your priorities lie. When it comes to addressing the parents, avoid false familiarity; for example, avoid meaningless terms of endearment. It is best to err, at least initially, on the side of formality and to address them as “Mr. and Mrs. Smith” (especially if their name happens to be Smith!) You should address parents by their first names only if they specifically request that you do so. Do not patronize parents.
The physical setting
Conduct the interview in a setting that offers privacy, comfort, and (as much as possible) no interruptions. Make sure the parents are not under special time constraints: Have they eaten? Are they late for work? Are other children due home from school?
Occupying the child
Always have age-appropriate play materials on hand to entertain and relax the child and any siblings who are along for the visit. Toys, puzzles, and coloring books provide more than mere diversion; watching children use play materials gives valuable insights into their development. In addition, gaining the child’s interest, confidence, and friendship early in the encounter can make all the difference between an easy physical examination and a difficult one.
Interview the child when possible
The child often is the most valuable informant in the family. Consider the following example, in which a 5-year-old child named Katie is brought to a physician because she is having frequent headaches:
Physician: “Katie, could you hold this finger up in the air?”
Katie holds up her index finger.
Physician: “Now Katie, show me with that finger exactly where your headaches start.”
Katie instantly points to her left supraorbital region.
Physician: “That’s great, Katie. Now tell me what kinds of things make your headaches worse?”
Katie identifies bright lights, watching TV, driving in the car, and loud noises.
This simple 30-second interview establishes with virtual 100% certainty that Katie is having migraine headaches. A family history confirms that Katie’s mother and two aunts have had migraines for years.
Note-taking
Nothing destroys the flow of an interview more than frequent pauses to take notes. Try to maintain eye contact with the people you are interviewing and take as few written notes as possible. Following these tips will facilitate the flow of the interview and leave you free to recognize important nonverbal cues (such as looks and gestures).
Different styles of questions
The value of answers to your questions often is determined by how you frame the questions. For example, to determine whether there is a family history of migraine in a child who complains of headaches, you can ask the key question in several possible ways. The reliability of the answer may depend heavily on how the question is framed.
Direct Question
The question, “Does anyone in your family have migraine?” is based on three assumptions:
Many persons do not have a clue about what the word migraine really means. Many adults have headaches that have been diagnosed previously as sinus headaches, tension headaches, or temporomandibular joint (TMJ) syndrome; however, a review of their symptoms sometimes reveals that they actually have characteristic migraine.
Because parents are often reluctant to admit that they do not understand a question, they may answer in the negative, thereby omitting important information.
An alternative style of questioning is to ask a directive (almost confrontational) type of question, expressed as an instruction: “Tell me who has headaches in your family.” This style of question, which is expressed in a totally different format than that of the direct question we previously considered, is far more likely to elicit a reliable and useful response. The format of this question differs from the earlier one in that:
The Open Permissive Question
Consider this depersonalized introduction to a question, “I don’t know about you, but many people who have a child with this problem….” This is an extremely effective introduction for bringing up sensitive issues such as guilt, sex, and fear of serious illness. As a nonaccusatory introduction to a question, it is less likely to elicit anxiety or to inhibit parents from discussing the subject. Merely acknowledging that most people in the same situation experience similar feelings or fears helps parents acknowledge similar concerns. Suppose, for example, that a child is brought to you because of pallor and cervical adenopathy. Parents rarely verbalize an overwhelming fear that the youngster may have leukemia. That frightening idea may stem from having known or heard of another child who had similar symptoms and turned out to have leukemia. Or the parents may simply have read about the disease or have seen a television program on the subject.
Parents of children who have minor signs or symptoms— that is, minor from your perspective—often harbor secret, unspoken fears that their child may have a serious or even a potentially fatal disease. Such fears can be far too upsetting to verbalize without some form of facilitation. Interviewers who fail to recognize the widespread prevalence of such fears, and who fail to alleviate them, may be overlooking the one truly important issue on the parents’ agenda. One investigation of more than 800 doctor-patient pediatric clinical encounters found that 24% of the parents had never revealed to the physician their single greatest concern!
An effective way to raise such covert issues is to say, “I don’t know about you, but many parents whose child has these symptoms worry that it might turn out to be something really serious.” Then pause and look for nonverbal acknowledgment, such as a slight affirmative nod of the head or a lowering of the eyelids (i.e., the inability to maintain eye contact). It is critically important to recognize and verbally acknowledge such signals by saying, for example, “I can see that you’ve been worried about this too.”
Parents may acknowledge their concerns verbally or nonverbally, for example, with an instant smile of relief or a nod of agreement. No matter how they express their concerns, do not postpone resolving the issue. Use the interview as therapy. Whenever possible, state or prove, immediately and unequivocally, that the child does not have the condition they are worried about. Equally important, try to identify the real source of their particular fears, which often is an affected relative or a friend whose diagnosis may have been missed at first assessment. Ask, “Who do you know who has had a child with that condition?”
The Offhand Screening Question
Some innocent-sounding questions, tossed casually into the conversation, can be incredibly valuable in screening for problems of parent-child interaction. Checking for parental depression is one example. An offhand question such as, “Are you having fun with the baby?” is useful because the repertoire of potential responses is limited. The most positive, reassuring answer is an instantaneous, emphatic “Yes!” or “Sure!” delivered with a smile or chuckle and with an immediate, positive nonverbal response. The latter response may include affectionate interaction between the parent and baby, such as eye contact, smiling, patting, or tickling. Any of these responses provides powerful prima facie evidence for a healthy parent-child relationship.
When a parent hesitates or responds with a puzzled look or a grudging affirmative answer, this response may suggest that the parent-child interaction may be less than ideal. The time lapse between the end of the question and the parent’s response sometimes can be a measure of the anxiety generated by the question.
Genuinely worrisome replies include an inability to respond, an unhappy downward gaze, a shaky voice, and tears, which are sure signs of difficulties that should lead to a quest for details. Resist any temptation to switch the conversation to another topic, as some interviewers do when they feel uncomfortable about having touched on a sensitive or painful area. Instead, immediately verbalize your recognition that there is a problem. Statements such as, “You don’t look very happy. Would you like to tell me about it?” may open the door for the parent to reveal the central concern, allowing you to begin dealing constructively with the parent’s distress.
The problem seen from different perspectives
In the classic Japanese film Rashomon, three witnesses to a murder give strikingly different individual accounts of the same dramatic event. Similarly, each of us may interpret the same situation in highly subjective ways. It is important to learn how each parent interprets a child’s problem. Having both parents present for the initial interview has many valuable payoffs. For one thing, it furnishes immediate insight into how the family works and an understanding about family dynamics that can help in your work with the individual members. Observe whether one parent is domineering or is a supportive leader of the family group. How does each parent relate to the child? How do the parents relate to each other?
In certain circumstances, it is essential to have both parents on hand. These situations include examination of the child with behavioral or learning problems, developmental delays, or a serious or chronic illness. Successful management often depends on negotiating an agreement with both parents that requires them to share the day-to-day responsibilities for treatment (see the later discussion on “The Therapeutic Contract.”
The parents’ opening statement
A good interviewer usually begins by asking parents to describe their main concern and their expectations of the visit. “Tell me why you’ve come to see me and how you think I may be able to help” is a useful opener. The most important sequel to this invitation is letting the parent or patient complete their opening statement without interruption. When patients’ opening statements have been analyzed, they have been rarely found to exceed 1.5 minutes. However, it also has been found that the majority of patients are never allowed to complete that statement because physicians so often interrupt with distracting questions based on their own agenda. Here is an example:
Patient: “Two weeks ago, Jack started to cough, and—”
Establishing the ground rules
After exchanging the opening pleasantries, making everyone comfortable, and listening without interruption to the parents’ or patient’s opening statement, you should describe the ground rules of the interview and its objectives. Explain that some questions may seem to have nothing to do with the child’s presenting problem but are nevertheless essential to a comprehensive medical evaluation. If the child is old enough to answer questions, involve him or her in the interview. Finally, always encourage parents to interrupt you if there is something they do not understand or if they have any questions or important issues they wish to raise.
Uncovering hidden agendas
In some families, the child acts as the “key in the door” in their search for help. Certain hidden agendas recur with remarkable frequency in pediatric clinical encounters. If you unearth such agendas, you can offer the family enormous help and relief. If you miss these issues, however, you may fail to relieve the family’s anxiety, even though you may have diagnosed and treated the presenting complaint or disease appropriately.
The presenting complaint may be excessive crying, abdominal pain, sleep disturbances, poor school performance, or headaches—all of which are common pediatric problems. Yet a sensitive interview may disclose that the family’s biggest problem is a depressed mother, a father who drinks excessively or is having an extramarital relationship, or serious financial difficulties. If the child’s symptoms are to be relieved, the physician must recognize and (when possible) remedy the root problem.
The child’s presenting complaint may or may not be the biggest problem. Sometimes the child is not even the real patient.
Parental Feelings of Guilt
Most parents who bring a child for medical attention feel some degree of self-blame for their child’s difficulties because of perceived sins of omission or commission. Their child’s clinical problem may be as routine as an earache, but a parent may speculate silently, “If only I hadn’t let him out without his sweater,” or “If only I had brought her to the doctor last week instead of waiting until now, maybe she wouldn’t be so sick.”
Recognizing how frequently self-blame occurs should help you uncover this issue during the initial interview and deal with it on the spot—another example of the interview as therapy. Reassurance that self-blame is universal and normal, that hindsight alone confers 20/20 vision, and that the child’s current condition could not have been predicted truly is a relief to most parents. To reveal the issue of self-blame, use a variation of the depersonalized question, such as, “I don’t know about you, but many parents I see wonder whether this problem was caused by something they had or had not done.” A pause is then appropriate. If there is no response, ask, “Have you worried about that sort of thing?”
Generally, the more serious a child’s problem, the more likely parents are to indulge in feelings of self-blame.
Feelings of guilt often are so deeply felt and so disturbing that parents cannot bring themselves to verbalize them spontaneously, even though the associated tension may be sensed by all concerned. These feelings are a typical result of a “secret” in the family: that is, feelings or situations, real or imagined, that family members know about but that no one dares mention, as if there were an unspoken pact of silence.
Feelings of self-blame for causing an illness often occur in families of children with developmental delays, multiple congenital anomalies, or a serious chronic disease. It is vital to ask the right questions to elicit the parents’ individual perceptions of what might have caused the problem, such as, “What are your thoughts about what might have caused her problem?”
Some time ago, I interviewed the father of a teenaged girl with a severe developmental delay. She had been seen by several physicians and had undergone various psychological assessments over the years, but her father clearly was still searching for something. During our conversation, I said, “I don’t know about you, but most parents of children with this condition have their own ideas about what may have caused it. What are your thoughts about what might have caused her problem?”
The girl’s father immediately exclaimed, “I know what caused this!” He then described walking beside a swimming pool with his daughter when she was 2 years old. He let go of her hand, and she fell into the pool. Although she was immersed for less than 30 seconds and had never lost consciousness, he was convinced that he was personally responsible for her condition. For all those subsequent years, he had remained silent, but he had always blamed himself for her misfortune. If no one had asked him that fundamental question, the issue would have remained unresolved for him, perhaps permanently. Because his daughter’s antecedent history made it clear that her development had never been normal, I was able to persuade the father that he was not culpable.
Sometimes one parent blames the other, either openly or secretly. If the marriage is unstable, this situation can be a serious problem calling for expert help.
Unarticulated Fears of Death
Many parents harbor unexpressed fears that their child may die, which is another common “secret” in some families. Becoming aware of how frequently parents fear serious illness and possible death in their children helps you to ask the key questions that will allow them to acknowledge their fears. You can then defuse their concerns quickly and unequivocally.
One of the most common clinical situations eliciting unexpressed parental fears of death occurs when a child has a generalized, febrile convulsion, usually a benign febrile seizure.
Although it is well documented that most parents who witness their child having a first febrile seizure believe that their child is actually dying (or has already died!), general pediatric and neurology textbooks often fail to mention this issue. This is a clear example of how medical teaching focuses more on disease (the physician’s problem) than on illness (the patient’s problem). Parents rarely express such fears spontaneously. Presumably, the mere thought is simply too frightening to verbalize. Even if the child never has another seizure, unless and until this fear has been confronted openly, parents may continue to live in fear of a repetition of the seizure and of the resulting death of their child.
Many physicians are reluctant to raise the issue of death if the parents have not done so, either because the topic makes them uncomfortable or because they believe they will upset the parents merely by mentioning the issue. But unless you help parents admit this fear and then deal with it unequivocally, any advice and reassurance you offer on other seizure-related issues will do little or nothing to relieve their anxiety. What you say may not even be heard because the parents are so preoccupied by this awful fear that they cannot bring themselves to put it into words.
As with other hidden issues, you should ask a depersonalized question, such as, “I don’t know about you, but many parents who have seen their baby have a convulsion tell me they were afraid the child was dying. Were you afraid of that?” If the parents acknowledge having this fear, either verbally or nonverbally, make the following points immediately:
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