When working with quiet or reserved patients assumptions can be made that the patient is disengaged, avoidant or closed off. Obtaining information from reserved patients can be challenging and the risk is that deeper exploration may not happen. Although it may just be the patient’s personality or communication style, there may also be other reasons behind their displayed behavior. These may include but are not limited to:

  • Fear of receiving a serious diagnosis or illness
  • Lack of trust in the medical establishment
  • Feelings of guilt, worthlessness, incompetence, shame
  • Loneliness, social isolation, depression
  • Denial
  • Fear of abandonment
  • Life stress
  • Cultural norms
  • Low medical literacy
  • Language issues
  • Memory disorder
  • Concern about personal safety: at home, on the street, other
  • Past abuse, sexual or other

 

Take your time and build rapport. That may be all you get done this visit and that is a lot.  The best friend of the primary care physician (and any physician with a continuity relationships) is the next appointment. 

In the vast majority of cases you will be very well served by asking open-ended questions.  With a patient like this, you may need to use more focused, closed-ended questions earlier in the encounter.   Remember that silence can be a gift.  Most of us are uncomfortable with silence and we tend to fill the space.  This is often because we are addressing our own anxieties.  Sitting in silence with empathy and curiosity may allow a patient to ease into the conversation and share more.   

Consider whether cognitive issues could be at play. Perhaps the history is better obtained from a family member or friend.  

Acknowledging that the interview is difficult for the patient and for you.  “I’d really like to be able to help you today, and I’m having trouble getting a sense of what brought you in.”   Consider “floating a hypothesis” about why the interaction may be challenging based on what you have been considering as potential underlying emotions or factors. “I wonder if this is hard to talk about (the weight loss) because you are really concerned something serious is going on?”

Be open with the patient that you want to develop a trusting relationship.  It may take time. 

Techniques that may help foster a therapeutic relationship

  • Take your time and build rapport.  
  • Use more focused, closed-ended questions earlier in the encounter. 
  • Consider whether cognitive issues could be at play
  • Acknowledge that the interview is difficult for the patient and for you.
  • Consider “floating a hypothesis” about why the interaction may be challenging
  • Be open to developing a trusting relationship
  • Empathize 

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The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.