Chapter 1General Medical History and Patient-Centred Communication Skills

• History – Gathering information about the patient’s subjective symptoms
  • History Taking is a Vital Skill: 80% of diagnoses come from history, 10% physical exam, 5% labs, 5% imaging
  • History taking is the focus of Chapter 1, and the first weeks of Clinical Skills small group sessions.
  • Subsequent chapters include a focused history and physical exam tests for a given clinical exam.
• Physical Examination – Observing the patient for objective signs of disease
• Investigations – Ordering appropriate diagnostic tests to support clinical assessment
• Assessment/Impression – Analyzing findings and Identifying the patient’s problems (Problem List generation)
• Plan – Develop and implement work-up and management plans to address each patient problem
• Documentation – Record all Subjective and Objective findings, Assessment, and Plan (SOAP Note framework –see Appendix 2). Your note should include the date and time (e.g. Sept 1/22 from 15:00 to 15:35 hours) of the clinical encounter.

• In Professional Competencies and in Clinical Skills, you will practice and receive feedback on your communication skills with peers and Standardized Patients (SPs) using the Kalamazoo Framework. In this chapter, we will focus on the first 4 steps of Kalamazoo – Building a Relationship; Open Discussion; Gather Information; and Understand Patient Perspective.
• The final 3 steps of the Kalamazoo Framework – Sharing Information; Reaching Agreement; and Providing Closure – are often performed after the physical exam in clinical encounters. In Pro Comp, these are practiced in the later Medical Foundations.
• Historically, “Clin Skills Interviews” focus on Gathering Info, whereas “Pro Comp Interviews” focus on other steps of the Kalamazoo Framework. In clinical practice, we must both practice patient-centred interviews and conduct a focused history and physical exam. To bring these elements together, Chapter 1 is structured according to the Kalamazoo Framework.
• Interview Observation Guides structured according to the Kalamazoo Framework are commonly used for feedback in communication skills sessions in Professional Competencies.

• Greet and show interest in the patient as a person.
• Uses words that show care and concern throughout the interview.
• Uses tone, pace, eye contact, & posture that show care & concern.

• Knock on door and ask for permission to enter the clinical interview space (respecting privacy)
• Share your name and role in patient care to open the encounter.
  • Example: My name is X, and I am a medical student working with Dr. Z in the clinic today.
• Tip: If you are comfortable sharing your pronouns, this is a good time to create a more welcoming space by introducing yourself with your own pronouns. Example: “My name is X, my pronouns are Y, and I am a medical student working with Dr. Z in the clinic today.”
• Wash hands: Recall the 4 moments of hand hygiene:
  • (1) before initial patient/patient environment contact (e.g. use hand sanitizer while walking into room)
  • (2) before aseptic procedure (if applicable)
  • (3) after body fluid exposure risk (if applicable)
  • (4) after patient/patient environment contact

• Ask the patient how they would like to be addressed. Reflect their name and pronouns during the visit.
  • Example 1: How would you like to be addressed?¹
  • Example 2: What would you like to be called today?
  • Example follow-up question: If you feel comfortable, could you share what pronouns you use?
• Note: Not all patients, including trans and non-binary patients, may be comfortable sharing their pronouns. If the patient is uncomfortable when asked their pronouns, clarify your goal is to ask patients’ pronouns routinely to create a welcoming space. Be accepting if the patient declines to share pronouns.
• Tip: If you make a mistake, apologize, use the correct pronouns, and move on. Example: “The patient reports he – I’m sorry I used the wrong pronoun. The patient reports she is experiencing dyspnea.”
• Tip: If someone is unsure of what a pronoun is, consider giving a brief explanation to clarify. Example: “Pronouns are how people refer to others without using their name, for example in your chart, a referral letter, or when talking to my supervisor. For example, they/them, he/him, she/her or other pronouns.”

• A clinician’s eye contact should be welcoming, friendly and show concern. Clinicians generally keep eye contact focused on the patient. The patient may look around to gather their thoughts, to process their emotions, etc. When the patient looks at the clinician, the clinician should meet their gaze in a natural and interested way. If you have to look away (e.g. to chart on the computer, to look up a medication dose, to answer a page), it can be helpful to verbalize why you’re looking away.

• A person’s voice tone, rate and volume are important in the process of communication – i.e. how something is said is important, alongside the content of what is said. It can be helpful to gauge the voice tone, rate and volume of voice of the patient, and mindfully adjust your own tone accordingly.
  • Voice tone can indicate diverse emotional responses (e.g. angry, frustrated, sad, excited, etc.)
  • Voice volume may be a balance in clinical interviews between privacy (e.g. in a shared clinical space with beds separated by curtains) and accessibility (e.g. if patient is hard of hearing) and indicate emotional response (e.g. becoming quiet when sad, or loud when angry)
  • Voice rate can indicate emotional response or importance (e.g. speak slowly to share a key detail or speak quickly to indicate a sense of urgency).
• Example: A patient’s tone becomes sad, their volume is lower, and their rate is slower, you might consider adjusting your voice to speak slower and softer, with tone showing added care and concern.

• Posture can demonstrate openness and interest in the patient, with suggestions including a direct body orientation (face the patient) with relaxed posture, forward lean, and uncrossed arms/legs. Notice when standing over a patient in a hospital bed, that this can reinforce a power differential – it is helpful to meet the patient at eye level e.g. sitting down.

• Gestures are used to enhance or add emphasis to our words. They may demonstrate active listening e.g. clinician mirroring the “elephant sitting on chest” sign for chest pain, or aid in asking questions e.g. using a question scale, using left hand to indicate one end of scale, right hand on other end of scale. Excess gestures can hinder verbal communication – be mindful when “talking with our hands”.

• Physical distance between the clinician and patient mediates the therapeutic relationship. A helpful framework from Hall² describes 4 zones of interpersonal distance – Intimate (less than 1.5 feet), Personal (1.5 – 4 feet), Social (4 – 12 feet) and Public (more than 12 feet), where comfort of having another person in each zone depends on their level of trust. In general, a comfortable distance with chairs about 4 feet apart is advisable, to adjust based on patient comfort level. You should ask permission to perform a physical exam as this requires more personal distances (e.g. 1.5-4 feet).

• A person may express a range of emotions – happiness, sadness, anger, fear, etc. with often subtle changes to facial expressions. Be mindful of your own facial expressions (seek feedback from peers and preceptors), and how you adjust your facial expressions in response to a patient’s expression.
• Example: To open interview, a clinician has a gentle smile. When the patient becomes tearful, the clinician adopts a more neutral or sad expression to mirror the patient’s expression. Or, when the patient becomes angry, the clinician mindfully maintains a neutral expression to de-escalate.

• Allow patient to complete opening statement without interruption.
• Asks “is there anything else?” to elicit full set of concerns.
• Explains and/or negotiates an agenda for visit.

Initial³: What brings you in to see us today? What sorts of troubles are concerning you today?

Sequential Questions Until List Exhausted²: What else did you want to discuss today? Other than X/Y/Z, what else did you want to be sure we begin to address today?

If there are specific agenda items that are concerning for you, speak up about these concerns to be sure to address e.g. I think it’s also important for us today to review the results of your recent X-rays.

Key Idea – Shared Decision Making: Working with patient to prioritize what needs to be addressed now (at this visit) vs. in follow-up (where possible). For example⁴:

• “I want to make sure I’ve heard all your concerns, and then we have to decide together what we can do today, which concerns to tackle, and perhaps which to save for another time.”

This step can also involve negotiation with the patient depending on the encounter. For example:

• “I see that you have several concerns today. Can you tell me what goes on the top of your list?”
• “I see you brought in a list today. Let’s decide where to begin in case we run out of time.”
• “We have [15, 30, etc.] minutes for today’s visit. What are the top 3 concerns you would like addressed today?”

• Key Idea – Confidentiality: Confidentiality is foundational for therapeutic trust. In specific circumstances (e.g. risk of harm to self or to others), our duty to protect or duty to warn may require us to break confidentiality. A confidentiality statement establishes these ground rules.
  • Note: This may change in pediatric/adolescent medicine (re. mandatory reporting), and reporting requirements vary by province. In Ontario, please see CPSO Policy on Mandatory Reporting.
• Example: The information you share with us will be kept confidential unless there is a significant risk of harm to yourself or to others. I might take notes and put those in your medical record here, but everything will be stored securely.

• Key Idea – Summarizing: Opportunity to finalize negotiated agenda and your role in the interview.
• Example: It sounds like you’re hoping to discuss your shortness of breath and cough today. I will start the visit today, asking you some questions and performing a physical exam. Afterwards, I will go back to review with Dr. Y, and we will come back to discuss next steps. Is this okay?

• Key Idea: It is vital, especially when opening the interview, to not interrupt patients.
• On average, doctors interrupt patients every 18 seconds⁵; resident physicians interrupt patients every 12 seconds⁶.
• In contrast, a recent study with a chronic pain clinic consultation found that patients were able to complete their opening statement with a mean time of 89 seconds⁵.

• Key Idea: Acknowledge and apologize for interrupting; empathize with the problem the patient is describing that you’ve interrupted; and explain why you are interrupting (e.g. planning time use in the interview, tracking topics, or stopping to explore an important social or emotional cue).
• Example 1: I want to come back to that, but first I want to understand all these concerns in order of importance.
• Example 2 Excuse me for a minute. Your knee has been painful. Before we talk further about this pain, I’d like to know if you have something else important to address today. This way you and I can figure out how to make the best use of our time.

• Examples: Make eye contact with the patient; lean in with body posture; consider hand gesture to capture attention (e.g. putting hand up; not necessarily touch)

• Begins with patient’s story using open-ended questions (e.g., “Tell me about…”)
• Clarifies details as necessary with more specific “yes/no” questions.
• Summarizes and gives patient an opportunity to correct or add information.
• Transitions effectively to additional questions.

• Open-ended questions allow the patient to respond with detailed responses and invite exploration and discussion. They are particularly helpful when starting a clinical interview or exploring a new topic, e.g.:
  • What: What brings you in today? What makes your pain worse?
  • Where: Where is the pain? Where is the swelling? Where does the pain travel to?
  • When: When did your cough start?
  • Who: Who are the important people in your life? Who lives with you?
  • Why: Why is that? Tell me more about that…
  • How: How would you describe this pain? How are you taking this medication? How are you feeling now?

• Close-ended questions limit the patient to a finite set of responses (e.g. yes/no). A mix of open-ended and close-ended questions is helpful. Close-ended questions can help gather details, for example:
  • Ruling out a red flag symptom: E.g. Is your shortness of breath happening at rest?
  • Evidence-based screening questions: E.g. Do you ever have difficulty making ends meet at the end of the month? (Screening question for Poverty – See Clinical Question 1 Below)
  • Assessing for Associated symptoms: E.g. Do you wake up in the middle of the night gasping for air?
  • Review of Systems: E.g. Do you have any headaches?
• Suggestion: You can follow-up a close-ended question with an open-ended question. For example:
  • Clinician close-ended question: Do you have any chest pain? → Patient: Yes
  • Follow-up clinician open-ended question: Tell me more about your chest pain

• Summarizing, Paraphrasing and Clarifying demonstrate active listening through the clinician reflecting on what the patient has said, either using the patient’s words (summarizing) or your own (paraphrasing). These skills allow us to test our understanding of what the patient has said and gives an opportunity for the patient to correct us (clarifying). These statements help transition interview topics, or to “check-in” to ensure common understanding e.g., after a significant amount of information has been shared.
  • Example Summarizing Statement: I’d like to recap what you’ve told me so far. 3 months ago, you had no trouble with your breathing when exercising. In the last 6 weeks, your breathing has gotten worse. Now you get short of breath going up 2 flights of stairs, but you’re comfortable if you’re sitting still.
  • Example Paraphrasing Statement: It sounds like in the past 6 weeks, your shortness of breath is now severely limiting your ability to do your day-to-day activities where you’re only comfortable at rest and minimal activity, but you used to be able to exercise without any issues.
  • Example Clarifying Question: Let me make sure I’ve got this right. Right now, you’re not able to go up 2 flights of stairs due to shortness of breath, and you manage by taking a rest after each flight. Is that right?

• Silence can allow the patient time to collect their thoughts and space to express their emotions. Silence can be a very useful tool to provide support and comfort to the patient.
• Suggestion: Pay attention to time you take before responding to a patient’s statement, or in responding to a patient’s question. Consider a few seconds before responding, particularly in a difficult conversation.

• Transitional statements create a sense of structure to the interview, including to change topics or focus.
  • Example: I’d like to move on to talking about your leg swelling.
  • Example: I’d now like to do a focused physical exam before stepping out to review with Dr. X.
  • Example: I’d like to go back to your earlier question about what we can do to help your breathing.

• Less Helpful: Compound questions combine more than one question before giving the patient a chance to respond. The patient may be uncertain how to respond. If the patient responds, it can be unclear to the clinician if they are responding to all or to only parts of the question. For example:
  • Clinician: Do you have any cough, shortness of breath at rest or fevers?
  • Patient: Yes (Clinician is uncertain which ones); or No (Are we certain the patient has none of these 3 symptoms? Perhaps they were responding to last item on list i.e., no fevers)
• Suggestion: If you catch yourself asking a compound question, acknowledge it and go back briefly
  • Example: Do you have any cough, shortness of breath at rest or fevers? … I’m sorry that wasn’t as clear, let me go back and try that again to make sure I get it right. First, do you have any cough?

• Less Helpful: Leading questions suggest a particular answer, where a patient may respond less truthfully if they perceive an expectation to respond a certain way. For example:
  • Clinician: You do not miss any doses of your Asthma puffers, do you?
  • Patient: Of course not (Consider – could the patient be responding differently out of worry the clinician may judge the patient for missing medication doses?)
• Suggestion: If you catch yourself asking a Leading Question, acknowledge it and go back briefly.
  • Example: You do not miss any doses of your Asthma puffers, do you?... Let me go back, that didn’t sound as I meant it to. Tell me more about how you’re taking your Asthma puffers?

• Do you have particular fears or concerns in thinking about your illness?
• What worries do you have about your illness?

• What do you think might be causing your symptoms?
• What is your understanding of what’s going on with your illness?

• How has your illness impacted your ability to function?
• How have you been coping with your symptoms?

• What are your expectations for today’s visit? How can I help?
• What are your hopes for today’s visit?

• It sounds like you are [frustrated, worried, sad]
• It sounds like you were anxious because you didn’t feel there was as much attention given

• I can’t imagine how difficult this must be
• This helps me understand what you’re thinking

• I can see you’ve really been trying to follow our instructions
• I think you’ve done a great job with this
• You’ve done an amazing job caring for your dad

• I will do my best to make sure you have what you need
• We are here to support you every step of the way. If there’s any way we can help, we’ll be there.

• Tell me more about…
• Could you say more about what you mean when you say…

• Patient-Centred Introduction (Communication Skill 1): My name is X, and I am a medical student working with Dr. Y in the clinic today. How would you like to be addressed?
• Key Data for Your Report: Name and Pronouns; Age; Ethnicity; Handedness (Neurological History); Sex; Gender; Occupation; Living Situation.
  • How did they present to clinic/hospital? Who was present in interview? (e.g. other learners)
  • Did you obtain collateral history? (e.g. family member – specify relationship) Was a translator used? (provide name)
• Example: Jane Doe is a 21-year-old left-handed Caucasian transgender woman (she/her) who works at McMaster and lives at home with her parents. She brought herself to our clinic today after developing abdominal pain.

Allow patient to complete their opening statement without interruption

• Agenda Setting (Communication Skill 3) - What brings you in to see us today? What else did you want to discuss today?
• CC = Chief Complaint (re. patient’s reason(s) for presenting to care) is different from RFR = Reason for Referral (A clinical question or aspect of management another clinician asked the patient to see you about)
• When preparing note: Use the patient’s own words for the Chief Complaint

When did it first begin? Was it sudden or gradual? Has this happened before?

Is it constant or does it come and go? What brings it on? What makes it better or worse? What treatments have you tried so far?

What does it feel like? Can you describe it?… Sharp? Dull? Cramping? Throbbing?

Where is the pain? Does it spread anywhere? Tip: Begin to learn your Dermatomes. Use anatomical terminology to describe radiation line, where it originates and terminates.

Quantify on 1-10 scale, 1 as minor discomfort, 10 as worst discomfort ever experienced…

Tip: Pain is a subjective experience, so with severity the numbers only mean something if you have their baseline e.g. is it better or worse than last time?

How long does it last? How often does it occur?

Purpose: ask high specificity questions and narrow in based on HPI/CC

• Key Idea: Associated symptoms help differentiate potential differential diagnoses (DDx) based on differing features of those pathologies (i.e. pertinent positives and pertinent negatives to rule in and rule out).
• In Early Pre-Clerkship: Your differential diagnosis (DDx) will likely be small – you may find casting a wide net via Review of Systems more manageable than targeted Associated Symptoms in initial clinical encounters.
• With Time: Throughout preclerkship, your differential diagnosis (DDx) will grow. Based on your top differential diagnoses, you can create a list of Associated Symptom Questions to ask, allowing you to gather information in a more focused way.
• In Clerkship: Based on a Chief Complaint, brainstorm Associated Symptoms to ask before beginning the assessment
• Starting point for Differential Diagnosis – VINDICATE: Common Etiologies on differential (DDx) for many Chief Complaints
  • V: Vascular; I: Infection; N: Neoplastic; D: Drugs; I: Iatrogenic; C: Congenital; A: Autoimmune; T: Toxic/Trauma; E: Endocrine
• Using this Guide: In each chapter, you’ll find important history items divided according to Chief Complaints and Associated Symptoms to ask. These lists are not exhaustive, focusing more so on high-yield questions you should ask i.e. questions that will help you rule in or rule out differential diagnoses, or otherwise impact management strategies you’re contemplating

I’m going to ask you a series of rapid questions head to toe, to make sure I didn’t miss anything…

• High Yield: Weight gain/loss, loss of appetite, fever, chills, night sweats, fatigue

• High Yield: Rashes, lumps, bumps or bruises
• Others: New or changing moles (ABCDE: Asymmetry, Border, Colour, Diameter, Evolution)

• High Yield: Headaches & Dizziness; Others: Trauma, dysphagia, syncope

• High Yield: Changes in your vision (blurred vision, diplopia); Others: Use of glasses, last eye exam

• High Yield: Changes in your hearing (hearing loss); Others: Tinnitus, noise exposure, last ear exam

• High Yield: Nosebleeds; Others: Nose discharge, snoring at night

• High Yield: Throat pain, ulcers or trouble swallowing
• Others: Condition of teeth, last dental exam, lumps, changes in voice

• High Yield: Cough, Short of breath; Others: Sputum (Amount, blood, colour, odour), last TB test

• High Yield: Chest Pain or Palpitations
• Others: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, light-headed, ECG/stress test History

• High Yield: Claudication, edema, ulcers, hair loss, discolouration

• High Yield: Lumps or discharge; Others: Tenderness, last mammogram

• High Yield: Constipation/diarrhea; nausea/vomit; Others: Reflux, abdo pain, melena, cancer screen

• High Yield: Dysuria (painful urination), frequency/urgency, nocturia, hematuria (blood in urine)
• Others: Incontinence, discharge, impotence

• High Yield: Discharge and Last Period? Is there any chance you could be pregnant?

• High Yield: Polyuria, Polydipsia, Skin Changes, Hair Changes, Heat/Cold Intolerance

• Question 1: Do you have any pain or stiffness in your muscles, joint or back?
• Question 2: Can you dress yourself completely without any difficulty?
• Question 3: Can you walk up and down stairs without any difficulty?

• High Yield: Numbness, tingling, memory loss or change in balance; Others: Seizures

• High Yield: Changes in mood; Others: Distress, depression, anxiety, panic attacks, psychosis, mania, substance abuse, suicidal ideation (SI) or homicidal ideation (HI)

• Acute or Chronic conditions; Past hospitalizations; Past major investigations (MRI, CT, etc.)

• What it was, opened up, when, what hospital…

• Diseases – age of onset, complications e.g. Cancers, Heart Disease, Diabetes (Type 1 or 2?), Hypertension, Dyslipidemia, Stroke, Asthma, COPD, Mental Illness, Addictions, Autoimmune Conditions
• Cause of Death and Age of Death Immediate Family: E.g. Myocardial Infarction in male relative < age 55, female before age 65→ ↑ patient risk of Myocardial Infarction

Name, Dose, Route, When Taken, How Long On…

• Route Abbreviations: P/O → Per Oral; P/R→ Per Rectal; SC: Sub-cutaneous; IV: Intravenous; Transdermal (= Topical); SL → Sublingual; IM → Intramuscular
• Timing Abbreviations: PRN → As needed; O/D → Once / day; BID → Twice / day; QAM → In the morning; QPM → At night-time; QHS → At bedtime
• Include any Over the Counter (OTCs)
• Polypharmacy (>5 medications, particularly important in Geriatric assessment): Assess how patient takes medications, their adherence with medications

Take any supplements…

What happens when rxn happens…?

• NKDA: No known drug allergy.
• Document specific reactions if stated: E.g. rashes, anaphylaxis

Are immunizations Up to Date (UTD)? Did you receive a flu shot this year? Last tetanus shot? COVID vaccinations?

• What are you doing for [name of health problem]?
• How is it going with your medicines? Diet? Exercise?
• Any problems, side effects, or challenges?
• What medicines are you taking? How are you taking them?

• Tell me about yourself.
• What language are you most comfortable speaking in?
• What is your sexual orientation?
• What pronouns do you use (e.g. he/she/they, her/him/them)? (Note: Although pronouns may correlate with someone’s gender or gender presentation, they do not always)
• Is spirituality or faith an important part of your life?

Why Ask: By learning about aspects of our patients’ identities, we help build effective rapport and can also tailor our care to be more patient centred. For example, by asking about language, we can identify if the patient would benefit from use of Medical Interpretation Services (See Appendix 1 for guidance on incorporating Medical Interpretation Services into your interview); by asking about spirituality, if pertinent we can screen for Spiritual Distress (See Below) and connect with appropriate services.

• Are there people in your life you can count on for support?
• Tell me about the important people in your life…
• Who lives with you at home?

Why Ask: By learning about the patient’s support network of family and friends, we get a sense of their important relationships. This can be important when approaching medical decision-making, for example to identify the patient’s substitute decision-maker (SDM) if they were not capable of decision-making.

Note: Family and caregivers often experience considerable mental, physical or economic stress in balancing a person with Intellectual and Developmental Disability (IDD)’s support needs with other responsibilities. When concerns arise, can monitor family or caregiver stress through the Brief Family Distress Scale¹¹

• ADL (Activities of Daily Living): DEATH - Dressing, Eating, Ambulating/Transferring, Toileting/Continence, Hygiene
• IADL (Instrumental Activities of Daily Living): SHAFT – Shopping, Housework, Accounting, Food prep, Transport/Telephone
• Assistance: Any caregivers (family, friends) or programs (e.g. community programs, Personal Support Worker, homecare) helping with ADLs or IADLs?
• Changes over time: Is patient needing more assistance with ADLs and IADLs? Over what period of time?

Why Ask: Exploring the patient’s function helps us gain an understanding of the patient’s perspective on their illness (See Communication Skill 7 – FIFE – Above). It can identify opportunities to support the patient’s function, for example connecting the patient with interdisciplinary supports (e.g. Speech and Language Pathology, Physiotherapist, Occupational Therapist, Personal Support Worker) to support their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

• Poverty Screen: Do you ever have difficulty making ends meet at the end of the month?¹² → If yes, continue¹³
  • All Patients: Have you filled out and sent in your tax forms?
  • Seniors: Do you receive Old Age Security (OAS) & Guaranteed Income Supplement (GIS)?
  • Families with Children: Do you receive the Canada Child Benefit on the 20th of every month?
  • Indigenous Peoples: Are you registered under the Indian Act or recognized by an Inuit Land Claim organization?
  • Social Assistance Recipients: Have you applied for extra income supplements?
  • Persons with Disabilities: Do you receive payments for disability?

Why Ask: The Poverty Screen is an evidence-based tool with 98% Sensitivity and 40% Specificity to identify patients struggling with Poverty (See Clinical Question 1 – Is this patient struggling with poverty?). With a positive Poverty Screen, consider also screening for Housing Instability and Food Insecurity (see Below). By screening for poverty, at the micro-level we can connect patients with resources to address this social determinant of health; at meso- and macro-levels, we can advocate for community- & systems-level change.

• Have you travelled in the past year? Where? Did you travel with anyone? How long were you there?
• How did you get water/food? Where did you stay?
• Did you visit a travel doctor prior to your trip? Did you have any medical complications while there?

Why Ask: Travel History may impact your Differential Diagnosis (e.g. a patient living at home develops a fever, versus a fever in a returning traveller). It also provides important opportunities for pre-travel counseling.

• Normalizing Opening Statement: Because traumatic events are so common and have direct, long-lasting effects on physical and mental health, I’ve begun to ask all my patients about stressful or difficult experiences they may have had.
• Have you had any significant negative experiences in your life that have left a lasting emotional impact on you?

Why Ask: A Trauma-Informed Care approach is essential (see Appendix 1, explored in Professional Competencies), where we do not need to know the specific trauma history in order to adopt a Trauma-Informed Care approach. In your clinical interview, if you do screen for Trauma history, you should first reflect on how you would respond if you had a positive trauma screen (e.g. are you aware of referral sources in your area, is there time in the interview today to explore this further if the patient wishes to do so)

• Where are you staying right now? What is your housing like?
• When did you last have a stable place to stay? Do you need help finding housing?

Why Ask: Asking about housing provides an important opportunity to identify patients experiencing Housing Instability, and patients experiencing or at risk of homelessness. If these concerns arise, consider completing a Housing Instability Screen (See Below)

• Are you working right now?
• What do you do for work? What other kinds of work have you done in the past?
• Do you have benefits through work such as drug coverage?

Why Ask: Employment is an important social determinant of health. Asking about health-related benefits can help us tailor our management (e.g. prescribing covered or low-cost medication). The patient’s employment may also carry occupational health concerns and prompt a Focused Occupational Health History (See Below). If unemployed, we may connect patients with services and support e.g. Resume-writing, employment services.

• How far did you go in school?
• Literacy Screen⁹: A lot of people have trouble reading things they get from the doctor because of all the medical words. Is it hard for you to read the things you get here at the clinic/hospital?

Why Ask: Asking about patient education and literacy can help us tailor patient information and communication and potentially connect the patient with supports e.g. Literacy Classes.

• Do you have any legal issues you need help with?

Why Ask: If a patient is currently experiencing contact with the legal system, we may connect the patient with services and supports if needed e.g. Legal Aid Clinics, ID Clinics. You may also consider an Incarceration History screen (See Below) which can carry significant stigma. This may also present an opportunity to reflect on your own attitudes and beliefs in caring for patients with a history of incarceration (See Chapter 3 for definitions).

• Physical Activity Vital Sign¹⁴:
  • On average, how many days per week do you engage in moderate to strenuous exercise (e.g. brisk walk)?
  • On average, how many minutes do you engage in exercise at this level? (Y minutes/day)
  • Minutes Per Week of Moderate-to-Strenuous Exercise = X days/week x Y minutes/day
• Sports: Sports position(s) played; current level of sport played (e.g. recreational, competitive, league level); and desired future sporting activity level
• Current training history: Quantity and quality of training; any recent changes to routines (e.g. training days per week, intensity, duration of training sessions)?

Why Ask:

• Physical activity is as powerful as most drugs in treating most chronic illnesses, where brief advice is a cost-effective intervention, you can engage in as a clinician. The first step is to assess where the patient is currently at with their exercise using the Physical Activity Vital Sign questions (from Exercise is Medicine¹³). How to support the patient around sustainable physical activity strategies using strategies such as Motivational Interviewing, Smart Goal Setting, etc. is explored in Chapter 38 – Prescribing Lifestyle Interventions in Medicine – Integration Foundation.
• For patients who participate in sports and training programs, it is helpful to know sports and positions played, current sporting level (e.g. recreational vs. competitive), current training level and desired future sporting level. Each sport has distinct risks for musculoskeletal injuries, where the mechanism of injury can help narrow your differential diagnosis for acute musculoskeletal injury. A recent change in training can increase risk of overuse injury. This is explored further in Section 4 – Musculoskeletal Clinical Skills – MF4.

• Do you have any safety concerns?
• Do you feel safe in your relationship?
• Has your partner ever hurt you? Your children?
• Do you feel safe in your home/neighbourhood?

Why Ask: If a patient identifies a safety concern in their relationships, it is important to screen for Intimate Partner Violence (See Below). When caring for patients who are elderly with safety concerns, it is important to screen for Elder Abuse (See Below).

Smoking History: Pack years = packs/day x years…Have you thought about quitting in the next 6 months?

• 5As approach taking smoking Hx: Ask smoking status, Advise to quit in personalized way, Assess willingness to change, Assist with resources, & Arrange Follow-up (F/U)

Alcohol History: How Often Do You Drink (Drinks/Week)? What is the size of 1 drink? What kinds of drinks?

• Ask Permission: Would it be all right for us to talk about your relationship with alcohol?
• Single Alcohol Screen Question (SASQ, screen for unhealthy alcohol use): In the past year, how often have you had more than 4 drinks (females) or 5 drinks (males) on any 1 occasion? (+ve screen = 1+ occasions)
• AUDIT-C Questionnaire (screening for risk of alcohol use disorder; including binge-drinking for patients who may not be alcohol dependent) – each item rated from scale of 0 to 4:
  • Q1: How often did you have a drink containing alcohol in the past year?
  • Q2: How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?
  • Q3: How often did you have 6 or more drinks on one occasion in the past year?
  • Scoring: Mild risk score 0-4; Moderate risk score 5-7; High risk score ≥ 8
• CAGE Questionnaire (screens for alcohol use disorder; may not capture binge drinking, not included in 2023 Canadian guideline for high risk drinking and alcohol use disorder¹⁵)
• Canada’s Guidance on Alcohol and Health focuses on a continuum of risk for weekly alcohol use¹⁶:
  • Standard drink: 12oz of 5% alcohol (e.g. beer); 5oz of 12% (e.g. wine); 1.5oz of 40% (e.g. spirits)
  • 0 Standard Drinks/Week: Not drinking has benefits such as better health, and better sleep
  • ≤2 Standard Drinks/Week: Likely to avoid alcohol-related consequences for yourself or others
  • 3-6 Standard Drinks/Week: ↑ Risk of developing several cancer types (e.g. breast, colon)
  • ≥7 Standard Drinks/Week: ↑ Risk of heart disease or stroke
  • Consuming >2 drinks per occasion: ↑ risk of harms to self and others (e.g. injuries and violence)
  • When pregnant or trying to get pregnant: No known safe amount of alcohol use
  • When breastfeeding: Not drinking alcohol is safest

Recreational Drug History¹⁷: Do you now use, or have you previously used any of the following substances:

• Marijuana (Clarify grams dried cannabis or # joints smoked per day or per week)
  • What is the Red Flag Level for Marijuana? 3 joints per week
• Prescription drugs for non-medical purposes
• Street drugs (e.g. cocaine, ecstasy, heroin, MDMA, etc.)
• There are modified AUDIT questionnaires for various drugs (e.g. CUDIT for Cannabis)
• Stages of Change (Motivational Interviewing, which has its roots in Addictions work): Pre-contemplation, Contemplation, Determination, Action, Maintenance

Why Ask: Screening for substance use helps identify important current and past patient risk factors. This can help inform a further exploration of Substance Use Disorders (See Chapter 37 – MF4), and opportunities to assess Stages of Change (See Chapter 38 – IF) and potentially connect the patient with supports. Key Idea: Social history includes, but is not limited to, sexual health and substance use history.

• Normalizing Opening Statements¹⁸: Is it okay if I ask you a few questions about your sexual health? Some of questions are very personal. I ask everyone these questions, and I consider them to be very important. You do not have to answer any questions you don’t want to.
• Confidentiality Statement: As with all of our visits, the information we discuss will be kept confidential. I might take notes and put those in your record here, but everything will be stored securely. There are some instances where I may be required by law to break confidentiality, for example if I believe there is immediate risk of harm to yourself or others. Does this sound okay with you?
• General Sexual History¹⁹²⁰:
  • Have you been sexually active in the past year?
  • How many partners have you had sex within the past year?
  • What is your partner’s gender? What gender or genders are the partners you’ve had sex within last year?
  • Do you have any sexual concerns you would like to discuss?

Why Ask: An understanding of current sexual function and practices is an important part of a patient’s history. A sexual history should be taken as part of a comprehensive health assessment – for example, during a patient’s initial visit, during routine preventive exams, or if there are concerns for Sexually Transmitted and Blood Borne Infections (STBBIs) for example. A sexual history identifies important current and past patient risk factors. In gathering a sexual history, it is important to remember that sexual behavior and not sexual identity puts individuals at risk for unplanned pregnancy and for contracting STBBIs - do not make assumptions about behavior or risk based on sexual orientation or gender. If concerns are raised, initial sexual history questions can be further explored as part of a Detailed Sexual History (Chapter 18 – MF3), including the 5Ps of Harm Reduction – Practices; Partners; Protection from Sexually Transmitted and Blood Borne Infections (STBBIs); Past History of STBBIs; and Pregnancy. Key Idea: Social history includes, but is not limited to, sexual health and substance use history.

Housing Instability Screen²¹: Since [current month] of last year:

• Was there a time when you were not able to pay the mortgage or rent on time? (Yes = +ve)
• How many places have you lived? (2+ in 12 months = +ve)
• Was there a time you did not have a steady place to sleep, or slept in a shelter (includes now?) (Yes = +ve)

Why Ask: A positive Housing Instability Screen is associated with significant adverse health outcomes, including outcomes for Child Health, Caregiver Health, and Hardship (See Clinical Question 3: Is this patient with Housing Instability at risk for adverse health outcomes?). By screening for housing instability, at the micro-level we can help connect the patients with resources to address these social determinants of health; at the meso- and macro-level, we can advocate for community- and systems-level change.

Quick Screen: Do you ever run out of money to buy food?

Food Insecurity Screen²²: I’m going to read you two statements people have made about their food situation

• Q1: “We worried whether our food would run out before we got money to buy more.” Was that often, sometimes or never true for your household in the last 12 months?
• Q2: “The food that we bought just didn’t last and we didn’t have money to get more.” Was that often, sometimes or never true for your household in the last 12 months?

Why Ask: The Food Insecurity Screen is an evidence-based tool to identify households at risk of Food Insecurity (See Clinical Question 2 – Is this family at risk for food insecurity?). This can be paired with your Poverty Screening Tool (see above). By screening for food insecurity, at the micro-level we can help connect the patients with resources to address this social determinant of health; at the meso- and macro-level, we can advocate for community- and systems-level change. The Food Insecurity screen is a shortened version of the 18-item Household Food Security Survey. Sensitivity and Specificity are:

• Approach 1 - 24-hour intake recall: To help me to get a sense of your nutrition, could you tell me what you had to eat and drink for the entire day yesterday? Walk me through the first thing you ate and drank after waking up, to when you went to bed. It’s also helpful to know times and amounts for each.
• Approach 2 – Ask patient to describe a typical day: To help me get a sense of your nutrition, it’s helpful to know what a typical day looks like for you. Can you walk me through the first thing you typically eat and drink after waking up, to when you go to bed? It’s also helpful to know times and amounts for each.
• Approach 3 – Dietary Food Log: To help me get a complete sense of your nutrition, it’s helpful to know what your nutrition looks like over time. If you could record all food, drink and snacks over a one-week period, with quantities and times, this would be very helpful.

1. Have you lost weight in the past 6 months without trying to lose this weight? (negative response if lost weight but gained back)
2. Have you been eating less than usual for more than a week?

Why Check: If answer to both questions YES, this ↑ malnutrition risk → Complete Subjective Global Assessment of Nutrition or refer for Nutrition Care in hospital.

The Canadian Nutrition Screening Tool is a validated questionnaire to flag patients in hospital settings who require nutrition care – Sensitivity >72.9%, Specificity 85.9%, with predictive validity for length of stay, 30-day readmission and mortality²⁴. Note that a knowledgeable informant is able to answer these questions on behalf of a patient if the patient themselves is unable to.

Environmental Exposure Assessment – Common Scenarios²⁵:

• Intake assessment for a new patient into the practice
• History of asthma, COPD, cardiovascular, allergic or autoimmune disease or unexplained exacerbations.
• Prenatal or preconceptual counseling
• Patient reports puzzling, non-specific symptoms; or presents with frequent visits for various illnesses

CH²OPD² Mnemonic (Community, Home, Hobbies, Occupation, Personal Habits, Diet, Drugs)²⁵:

• Community: Do you live near an industrial plant or a busy road? Where have you lived in the past?
• Home: How old is your home? Have you done any renovations that might result in exposure to lead paint or other dust? Do you have pets or large numbers of indoor plants? Is there a wood burning stove/ fireplace? Does your home have recurrent moisture problems? Does the home have an air conditioner?
• Hobbies: What are your hobbies? Do you use oil-based paints or varnishes?
• Occupation: What is your current job? Could you be exposed to any chemicals, fumes or dust? What was your past occupation?
• Personal Habits: Do you or does anyone in your home smoke? Do you exercise outdoors?
• Diet: Where does your drinking water come from? Do you regularly eat fresh tuna or sportfish (e.g., king mackerel, marlin, shark, swordfish, tilefish)?
• Drugs: Are you taking any over-the-counter drugs or complementary/alternative remedies?

Next Steps: If concerns for site-specific exposures are suspected, a more extensive history should explore the potential exposure risks for the patient. Detailed forms help facilitate the assessment

Why Ask: In Canada, deaths from modifiable environmental risks account for 9-14% of all mortality²⁶. Environmental health problems frequently present as common medical problems (e.g. headache, difficulty concentrating, behavioral problems, rashes, asthma, angina, myalgia, difficulty conceiving, spontaneous abortions) or non-specific symptoms. Through an appropriate environmental and exposure history, clinicians may identify opportunities to influence the course of disease for an individual patient and prevent the disease for other patients through stopping or avoiding exposures²⁷. An efficient approach to identifying potential for exposure involves searching for a change in the environment, rather than looking for a specific exposure. Where concerns are identified, a more detailed history should be gathered. Exposure types include²⁵:

• Biological: Moulds/fungi; bacteria; viruses; dust mites; pet dander/saliva/feathers; pollen
• Physical: Heat; cold; noise; ionizing radiation (e.g. Radon gas through cracked foundations, nuclear power plants, X-rays, radiotherapy); non-ionizing radiation (e.g. sunlight exposure); Electromagnetic radiation (e.g. electrical equipment, high-tension power lines)
• Chemical Exposures: Metals (e.g. aluminum, cadmium, chromium, copper, arsenic, lead, mercury); Fibers (e.g. asbestos, fibreglass); Inorganic compounds (e.g. fluorides, nitrates, nitrites, nitrogen dioxide, sulfur dioxide, ozone, phosphates, silicon dioxide, sodium hypochlorite, sulfites)

Examples of Environmental and Occupational Causes of Medical Problems (Centres for Disease Control)²⁷:

Immediate or Short-Term Effects

Latent or Long-Term Effects

Focused Occupational Health History²⁸: Relevant exposures, etc. WSIB if injury potentially work-related.

• What do you do at work and how do you do it?
• Exposure History (Intensity & Duration): How was the task performed? - Was the dust concentration so thick that no one could see through it clearly? Was the noise so loud that communication was difficult? What quantity of the chemical was handled? For how long?
• Harm Reduction: Is there attempt at segregating harmful tasks, or providing local exhaust ventilation? Is personal protective equipment used? What control measures to reduce exposures are in place?

Why Ask: Taking an occupational history is an important tool for identifying whether an illness or condition is occupational (i.e. whether it is work-related). See Chapter 3 for important definitions, including Workplace Safety and Insurance Board (WSIB), Worker, Workplace, Supervisor and Employer. The College of Family Physicians of Canada has a helpful Occupational History guide for a more detailed Occupational History.

Intimate Partner Violence Screen: I am concerned about my patients’ health and safety. I ask all my patients…

SAFE Questions²⁹:

• Stress/Safety – Do you feel safe in your relationship?
• Afraid/Abused – Has your partner ever threatened or abused you or your children?
• Friend/Family – If you were hurt, would your friends or family know? Would they be able to help you?
• Emergency Plan – Do you have a safe place to go and resources you need in an emergency?

If concerns identified above, continue to HITS Questionnaire³⁰ (© Kevin Sherin MD, MPH):

• Hurt – How often does your partner physically hurt you?
• Insult – How often does your partner insult or talk down to you?
• Threaten – How often does your partner threaten you with physical harm?
• Scream – How often does your partner scream at you?

Why Ask: Screening for Intimate Partner Violence is essential, particularly if the patient identifies a safety concern in the interview. The HITS Questionnaire (See Clinical Question 4: Is this Patient in a Relationship with Concerns for Intimate Partner Violence?) is a validated screening tool for identifying Intimate Partner Violence for both female survivors with LR+ 10.97 and LR- 0.04; and for male survivors with LR+ 34.41 and LR- 0.12. It is also important to remember that equity-deserving populations (LGBTQ2S+, trans and gender non-conforming, BIPOC, and people with disabilities) are at greater risk for experiencing IPV. The SAFE Questionnaire is a well-established tool and is also helpful as it asks specific questions about safety planning. See Chapter 3 for important definitions concerning Intimate Partner Violence.

Elder Abuse Screen³¹: Within the past 12 months:

1. Have you relied on people for any of the following: Bathing, dressing, shopping, banking or meals?
2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care or from being with people you wanted to be with?
3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?
4. Has anyone tried to force you to sign papers or to use your money against your will?
5. Has anyone made you afraid, touched you in ways that you did not want or hurt you physically?
6. Elder abuse may be associated with findings such as poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing or medication compliance issues. Did you notice any of these today or in the past 12 months?

Why Ask: The Elder Abuse Screen (See Clinical Question 5: Is This Elderly Patient at Risk of Elder Abuse?) is a validated screening tool with high specificity of 96-97% when 2 or more screening questions are positive. See Chapter 3 for important definitions concerning Elder Abuse, and Care of the Elderly.

Incarceration History Screen³²: A lot of my patients and their family members have experienced incarceration in the past, and this can affect how healthy people and their families are. Has this ever happened to you or a loved one? → If Yes: What was that experience like for you?

Why Ask: Patients with current or past history of contact with the legal system, including incarceration may face significant stigma. This may present an opportunity to reflect on your own attitudes and beliefs in caring for patients with a history of incarceration (See Chapter 3 for definitions).

Do you struggle with the loss of meaning and joy in your life?

Do you currently have what you would describe as religious or spiritual struggles?

Why Ask: Spiritual assessment is an opportunity for physicians to support patients through empathetic listening, documenting spiritual preferences for future visits, incorporating precepts of patient spirituality into treatment plans, and encouraging patients to use resources of spiritual traditions and communities³⁴.

Adjusted OR+ve (95%CI) per Adjusted Housing Condition (AHC) Questionnaire

Spirituality is “the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.” (https://goo.gl/8CEBH8. Accessed Mar 12/19).