A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?


How do we not only know medicine but know the human condition? Read Shakespeare? Go to bedside medicine skills sessions with actors? Do an ED fellowship in emergency psychiatry?


I particularly enjoyed reading the articles by Frederick Platt from the University of Colorado. He was an internist who would put on workshops on difficult patients/encounters. In role playing, the clinician would learn to recognize strong affect, stop, and name the affect. “I sense you are feeling…upset…scared…angry…etc.” The patient then is invited to explain their fears and concerns.


Emotions, as the Latin root “motere” tells us, serve to “move” us. They motivate us and impel us to action. They are faster and more intuitive than verbal language. But they are not enough for us. We need to move the patient from nonverbal to verbal expression.


“I sense you are feeling scared.”


The patient starts crying. You ask why she is scared.


She is afraid of dying.


You then address that fundamental concern with her. You write “fear of death” as the diagnosis, knowing that future providers can at a glance review the primary diagnosis for each visit. As your colleagues and you empathetically address her concerns, the visits drop from daily to weekly to a couple times a year. She starts taking care of herself better and gets off the sedatives.



-if there is strong affect, stop, name it, and inquire about it

-transition the patient from nonverbal to verbal communication

-identify the concerns and needs behind each visit with a question like “what concerns you the most?”

-review the post on agenda setting for related suggestions



Patients often lie about drug use and that can interfere with care. Part of practicing emergency medicine is using skill in communication to get through those communication pitfalls.


To get patients to tell the truth on drug use, start with asking about past use. Then ask current.


Furthermore, sometimes it helps to ask the question specifically In my area, I tend not to ask “do you use drugs?” I ask “did you try amphetamines when you were younger?”


If they answer affirmatively then can expand to “when was the last time?”


If you have doubts about their answer, you can say “may I test your urine and confirm?” Their response is often revealing.



-Ask about past drug use first

-Then ask about recent drug use

-Ask permission for a drug screen


It is possible to adequately address a chief complaint but not identify or meet the patient’s concerns.

Agenda setting is defined as that process of the medical encounter where the doctor and patient agree on the plan for the visit. If agenda setting is not done, it defaults to whatever the doctor thinks is needed, and sometimes patients feel their concerns were not addressed.

Interpersonal skills are often portrayed as something we do in addition to our normal duties. The implication is that it would add time demands. But a group of researchers reported that certain interpersonal skills actually saved time.(Mauksch Arch Intern Med 2008) Those skills included rapport building, empathy, and agenda setting.

How do we conduct agenda setting? Here are two scripted phrases:

“What concerns you the most?” (addresses the patient’s fears)

“How can I be of most help to you?” (addresses the patient’s goals)

Another way of asking the second question is “what is your goal for this visit?” or “what would you most like to see accomplished?”

When we ask those sorts of questions we are identifying the patient’s concerns and needs, and setting the course for a more effective patient encounter.

Take home points:

-Set the agenda for the visit collaboratively with the patient

-“What concerns you the most?”

-“What would you most like to see accomplished today?”


Studies show that patients omit symptoms when explaining their history to the doctor. I see this in academics when I get a story that adds information compared to what the resident elicited. When I observe resident history taking directly, I sometimes can gain insight into optimal and suboptimal medical history taking.

Interruptions can be well-intentioned, but studies show they may prevent the patient from giving all the symptoms. Patients get off track and never finish. I recommend starting with a request for the whole story, or some such variant, and then listening without interruption. Facilitative questions are okay, like “tell me more” or “tell me more about the onset.” I usually don’t ask those until they are done talking.

At the end, I like to ask “what else?” Some patients, no doubt used to the medical system and perhaps also out of politeness, give very brief presentations. I want them to know they have permission to give more information.

A full account of symptoms in some cases is the most important factor in making the diagnosis. Patients often leave out key information, so taking a full and open history without interruption is key to medical diagnosis.

Take home points:
Start the medical history with an open invitation
Do not interrupt
Use facilitative questions to get more information “tell me more about…”
At the end ask “what else?”