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 a LANGE medical book

Behavioral Medicine
A Guide for Clinical Practice
Fifth Edition
Editors
Mikhell D. Feldman, MD, MPhil, FACP
Professor ofMedicine
Chief. Division ofGeneral Internal Medicine
Associate Vice Provost, Faculty Mentoring
University of California, San Francisco
San Francisco, California

John F. Christensen, PhD

Healthcare Consultant
Corbett, Oregon

Associate Editors
Jason M. Satterfield, PhD
Professor ofMedicine
University of California, San Francisco
San Francisco, California

Ryan Laponis, MD, MS

Associate Professor ofMedicine
University of California, San Francisco
San Francisco, California

New York Chicago San Francisco Athens London Madrid

Mexico City Milan New Delhi Singapore Sydney Toronto
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 Contents

Videos
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•
[!] .

Authors .......................................................................... vii

Foreword ........................................................................ xvii

Preface........................................................................... xix:

Acknowledgments .................................................................. m

SECTION I: THE DOCTOR & PATIENT

1. Th.c Medical lntcf'View' ••............•••••••............•••••............•••••••. . 1
M1tek Lipkin, fr., MD &- Antoinette Schoenthaler, EdD

2. Empatliy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Auguste H. Fortin Vl MD, MPH

3. Delivering Seriom News ............•••••............•••••••............•••••.... 24

Bethany C c.a/kins, MS, MD & Timothy E. Quill, MD, MACP, FAAHPM

4. Diffi~t Patients/Diffi~t Situations ...•••••••............•••••............•••••••. 33

Ryan Laponis, MD, MS &- MitcheO D. Feldman, MD, MPhi' FACP

5. Suggestion & Hypnosis ...... ................................................... . 43

John R Christmten, PhD

6. Practitioner Well-Being •............•••••............•••••••............•••••.... 54

Anthony L. Suchman, MD & Gita Ramamurthy. MD

7. Min.clful Practice ............................................................... 61

Ronald Epskin, MD

Ill
Iv I CONTENTS

SECTION II: GLOBAL HEALTH

8. Global Health and Behavioral Medicine ............................................. 67
Patrick T. Lee, MD, DTM&H; KavithaKo/appa. MD, MPH; & Giuseppe]. Ravio/a, MD, MPH

9. Environment, Health, and Behavior ................................................ 77

John R Christensen, PhD

10. Training oflnternational Medical Graduates ......................................... 88

H. Russell Searight, PhD, MPH; Jennifer Gafford, PhD; & Vishnu. Mohan, MD, MB!, FACP, FAM/A

SECTION III: WORKING WITH SPECIFIC POPULATIONS

I I. Families ...................................................................... 99
Mitchell D. Feldman, MD, MPhil FACP & Steven R. Hahn, MD

12. Children ..................................................... .. . .. .. .. . .. .. . I 16

Adam L. Braddock, MD, MPhil & Howard L. Taras, MD

13. Adolescents .................................................................. 127

Lawrence S. Friedman, MD

14. Older Patients ................................................................ 137

Elizabeth Eckstrom, MD, MPH; Leah Kalin, MD; & Nicholas Kinder, MSN, APN, AGNP-C

15. Cross-Cultural Communication •..•...•..•..••..•..•...•..•...•..•..••..•..•...•. 148

Thomas Denberg, MD, PhD & Mitchell D. Feldman, MD, MPhil FACP

16. Women ..................................................................... 160

Diane S. Morse, MD; Misa Perron-Burdick, MD, MAS; & Judith Walsh, MD, MPH

17. Lesbian, Gay; Bisexual, Transgender, & Queer Patients ..•...•..•...•..•..••..•..•...•. 172
Richard E. Greene, MD, MHPE, FACP; Jason Schneider, MD, FACP; & Tiffany E. Cook, BGS

18. Vulnerable Patients ............................................................ 182

George W. Saba, PhD; Neda Ratanawong.ra, MD, MPH; Teresa Vilkla, MD; & Dean Schillinger, MD

SECTION IV: HEALTH-RELATED BEHAVIOR

19. Behavior Change .••..•..•...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•. 193
Daniel O'Connell, PhD

20. Patient Adherence ............................................................. 200

~ronica f. Sanchez, PhD & M. Robin DiMatteo, PhD

21. Tobacco Use .•..••..•..•...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•. 205

Nancy A. Rigotti, MD & Sara Kalkhoran, MD, MAS

22. Obesity ..................................................................... 215

Robert B. Baron, MD, MS
 CONTENTS I v

23. Eating Disorders •...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•..•...•.. 224

Erin C. Accurso, PhD & Sarah Forsberg, PsyD

24. Unhealthy Alcohol & Other Substance Use ......................................... 233

Derek D. Satre, PhD; J. Carlo Hojilla, RN, PhD; Kelly C. YtJung-Woljf, PhD, MPH;
& E. Jennifer Edelman, MD, MHS

25. Opioids ..................................................................... 251

Stephen G. Henry, MD, MSc

SECTION V: MENTAL & BEHAVIORAL DISORDERS

26. Depression..•..•...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•..•...•.. 269

Y. Pritham R.aj, MD; John E Christensen, PhD; & Mitchell D. Feldman, MD, MPhil FACP

27. Anxiety ..................................................................... 301

Jason M. Satterfield, PhD & Mitchell D. Feldman, MD, MPhil FACP

28. Attention Deficit Hyperactivity Disorder ........................................... 313

H. Russell Searight, PhD, MPH & Taylor Severance, BS

29. Somatic Symptom & Related Disorders ............................................ 322

Y. Pritham R.aj, MD

30. Personality Disorders.•..•...•..•..••..•..•...•..•...•..•..• •. .• .. • .. .• . .• .. .• . . 335

John Q. Ytiung, MD, MPP, PhD & Timothy R. Kreider, MD, PhD

31. Psychosis •..•..•...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•..•...•.. 354

Olesya Pokorna, MD & Emma Same/son-Jones, MD

32. Sleep Disorders ............................................................... 368

David Cla.man, MD; Karli Okeson, DO; & Clifford Singer, MD

33. Sexual Problems .............................................................. 386

David G. Bullard, PhD & Christine Derzko, MD

34. Dementia & Delirium.......................................................... 410

Leah Kalin, MD; Nicholas Kinder, MSN, APN, AGNP-C; & Elir.abeth Eckstrom, MD, MPH

SECTION VI: SPECIAL TOPICS

35. Integrative Medicine ........................................................... 421

Selena Chan, DO & Frederick M Hecht, MD

36. Stress &: Disease .............................................................. 429

John E Christensen, PhD

37. HIV/AIDS ................................................................... 446

Elir.abeth Imbert, MD, MPH & Mitchell D. Feldman, MD, MPhil FACP
vl I CONTENTS

38. Pain ........................................................................ 454

Michael W. Rabow, MD; Gregory T. Smith, PhD; Ann C. Shah, MD; & Steven Z. Pantilat, MD

39. Errors in Medical Practice ....................................................... 479

John F. Christensen, PhD

40. Intimate Partner Violence ....................................................... 490

Mitchell D. Feldman, MD, MPhil FACP & Gina Moreno-John, MD

41. Trauma ..................................................................... 497

Coleen Kivlahan, MD, MSPH; Edward L. Machtinger, MD; & Nate L. Ewigman, PhD, MPH

42. Palliative Care, Hospice, &: Care of the Dying ..••..•..•...•..•...•..• .. • •. .• .. • .. .• . 507
Bethany C. Calkins, MS, MD; Michael Eisman, MD; & Timothy E. Quill, MD, MACP, FAAHPM

SECTION VII: TEACHING AND ASSESSMENT

43. Competency-Based Education for Behavioral Medicine ................................ 521
Jason M. Satterfield, PhD & Eric S. Holmboe, MD

44. Teaching Behavioral Medicine: Theory &: Practice .................................... 531

Debra K Litzelman MA, MD; Mark DiCorcia PhD; Ann Cottingham MAR. MA;
& Thomas S. lnui ScM, MD, MACP

45. Assessing Learners &: Curricula in the Behavioral &: Social Sciences ...................... 547
Patricia A. Carney, PhD; Felise Milan, MD; &Jason M. Satterfield, PhD

46. Evidence-Based Behavioral Practice.•...•..•..••..•..•...•..•...•..•..••..•..•...•. 556

Bonnie Spring, PhD, ABPP & Stephen D. Perse/l, MD, MPH

47. Narrative Medicine •..•..•...•..•...•..•..••..•..•...•..•...•..•..••..•..•...•. 561

Jonathan Amie£ MD; Anne Armstrong-Goben, MD; Melanie Bernitz, MD, MPH;
Hetty Cunningham, MD; Julie Glickstein, MD; Deepthiman Gowda, MD, MPH, MS;
Gillian Graham, MS, PMHNP-BC; Nellie Hermann, MFA; Constance Molino Park, MD, PhD;
Delphine Taylor, MD; & !Ota Charon, MD, PhD
48. Educating for Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Richard M. Frankel PhD & Frederic W. Hafferry, PhD

49. Trainee Well-Being ............................................................ 578

John F. Christensen, PhD & Mitchell D. Feldman, MD, MPhil FACP

Index........................................................................... 589
 Authors

Erin C. Accurso, PhD Adam L Braddock, MD, MPhil

Department of Psychiatry, Weill Institute for Assistant Clinical Professor of Pediatrics
Neurosciences Division of Academic General Pediatrics,
University of California, San Francisco Child Development, and Community Health
San Francisco, California University of California, San Diego School of
Erin.Accurso@ucs£edu Medicine
Chapter 23: Eating Disorders San Diego, California
[email protected]
Jonathan Amid, MD Chapter 12: Children
Associate Professor of Psychiatry
Columbia University Vagelos College of Physicians David G. Bullard, PhD
and Surgeons Clinical Professor of Medicine
New York State Psychiatric Institute, Clinical Professor of Medical Psychology (Psychiatry)
NewYork~Presbyterian Hospital Consultant, Symptom Management Service
New York, New York Helen Diller Family Comprehensive Cancer Center
[email protected] Member, Professional Advisory Group, Spiritual
Chapter 47: NaTTlltive Medicine Care Services
UCSF Medical Center and UCSF Benioff
Anne Armstrong-Cohen, MD Children's Hospital
Associate Professor of Pediatrics at Columbia Private Clinical Practice of Individual and
University Irving Medical Center Couples Therapy
Columbia University Vagelos College of Physicians San Francisco, California
and Surgeons [email protected]
NewYork-Presbyterian Hospital, Morgan Stanley Chapter 33: Sexual Problems
Children's Hospital of New York
New York, New York Bethany C. Calkins, MS, MD
[email protected] Palliative Care Physician
Chapter 47: NaTTlltive Medicine VA Western New York Health Care System
Buffalo, New York
Robert B. Baron, MD, MS [email protected]
Professor of Medicine Chapter 3: Delivering Serious News
Associate Dean for Graduate and Continuing Chapter 42: Palliative Cart, Hospice, & Cart ofthe
Medical Education Dying
Vice Chief, Division of General Internal Medicine
University of California, San Francisco Patricia A. Carney, PhD
San Francisco, California Professor of Family Medicine
[email protected] Oregon Health & Science University
Chapter 22: Obesity Portland, Oregon
[email protected]
Melanie Bemitz, MD, MPH Chapter 45: Assessing Learners & Curricula in the
Associate Vice President and Medical Director
Behavioral & Social Sciences
Columbia Health
Associate Clinical Professor of Medicine
Columbia University
Columbia University Irving Medical Center
New York, New York
[email protected]
Chapter 47: NaTTlltive Medicine
vii
viii I AUTHORS

Selena Chan, DO Betty Cunningham, MD

Health Sciences Clinical Instructor, School of Assistant Professor of Pediatrics at Columbia
Medicine University Irving Medical Center
Osher Center for Integrative Medicine Columbia University Vagelos College of Physicians
University of California, San Francisco and Surgeons
San Francisco, California NewYork-Presbyterian Hospital, Morgan Stanley
[email protected] Children's Hospital of New York
Chapter 35: Integrative Medicine New York, New York
hc45 [email protected]
Rita Charon, MD, PhD Chapter 47: Narrative Medicine
Professor and Chair, Medical Humanities and Ethics
Professor of Medicine at Columbia University Irving Thomas Denberg, MD, PhD
Medical Center Senior Medical Director
Columbia University Vagelos College of Physicians Medical Operations and Healthcare Strategy
and Surgeons Pinnacol Assurance
Columbia University Irving Medical Center Denver, Colorado
New York, New York [email protected]
[email protected] Chapter 15: Cross-Cultural Communication
Chapter 47: Narrative Medicine
Christine Derzko, MD
John F. Christensen, PhD Associate Professor
Healthcare Consultant Department of Obstetrics & Gynecology
Corbett, Oregon Department of Internal Medicine (Endocrinology)
[email protected] University ofToronto
Chapter 5: Suggestion & Hypnosis St. Michael's Hospital
Chapter 9: Environment, Health, and Behavior Toronto, Ontario, Canada
Chapter 26: Depression [email protected]
Chapter 36: Stress & Disease Chapter 33: Sexual Problems
Chapter 39: Errors in Medical Practice
Chapter 49: Trainee Welt-Being Mark DiCorcia, PhD
Assistant Dean for Medical Education and
David Oaman, MD Academic Affairs
Director, UCSF Sleep Disorders Center Associate Professor of Integrated Medical Science
UCSF Professor of Medicine Charles E. Schmidt College of Medicine at Florida
San Francisco, California Atlantic University
David.Claman@ucs£edu Boca Raton, Florida
Chapter 32: Sleep Disorders [email protected]
Chapter 44: Teaching Behavioral Medicine: Theory &
T'dfany E. Coo~ BGS Practice
New York University School of Medicine
New York, New York M. Robin DiMatteo, PhD
[email protected] Distinguished Emerita Professor of Psychology
Chapter 17: Lesbian, Gay, Bisexual, Transgender, & University of California
CJ.!'eer Patients Riverside, California
[email protected]
Ann Cottingham, MAR, MA Chapter 20: Patient Adherence
Director, Research in Health Professions Practice and
Education Eli7.abeth Eckstrom, MD, MPH
Center for Health Services Research Professor and Chief, Geriatrics
Regenstrief Institute Division of General Internal Medicine and Geriatrics
Indiana University School of Medicine Oregon Health & Science University
Indianapolis, Indiana Portland, Oregon
[email protected] [email protected]
Chapter 44: Teaching Behavioral Medicine: Theory & Chapter 14: 01.der Patients
Practice Chapter 34: Dementia & Delirium
 AUTHORS/ Ix

E. Jennifer Edelman, MD, MHS Auguste H. Fortin, VI, MD, MPH

Associate Professor of Medicine and Public Health Professor of Medicine
Yale Schools of Medicine and Public Health Division of General Internal Medicine
New Haven, Connecticut Yale School of Medicine
[email protected] Director of Psychosocial Communication
Chapter 24: Unhealthy Alcohol & Other Substance Use Yale Primary Care Internal Medicine Residency
Program
Michael Eisman, MD New Haven, Connecticut
[email protected] [email protected]
Chapter 42: Palliative Care, Hospice, & Care ofthe Chapter 2: Empathy
Dying
Richud M. Frankel, PhD
Ronald Epstein, MD Professor of Medicine and Geriatrics
Professor of Family Medicine, Psychiatry, Oncology Indiana University School of Medicine
and Medicine (Palliative Care) Director: Advanced Scholars Program for
American Cancer Society Clinical Research Professor lnternists in Research and Education
University of Rochester School of Medicine and Indianapolis, Indiana
Dentistry Education Institute
Rochester, New York Cleveland Clinic
[email protected] Cleveland, Ohio
Chapter 7: Mindful Practice [email protected]
Chapter 48: Educating for Professionalism
Nate L Ewigman, PhD, MPH
Staff Psychologist and Associate Director, Lawrence S. Friedman, MD
IMPACT Team Associate Dean for Clinical Affairs
San Francisco VA Health Care System Professor of Clinical Pediatrics and Medicine
Clinical Assistant Professor of Psychiatry University of California, San Diego Health System
University of California, San Francisco and School of Medicine
San Francisco, California San Diego, California
[email protected] [email protected]
Chapter 41: Trauma Chapter 13: Adolescents

Mitchell D. Feldman, MD, MPhil, FACP Jennifer Gafford, PhD

Professor of Medicine Licensed Psychologist
Chief, Division of General Internal Medicine Behavioral Health Consultant at Family Care
Associate Vice Provost, Faculty Mentoring Health Centers
University of California, San Francisco Director of Behavioral Medicine Education
San Francisco, California Saint Louis University Family Medicine Residency at
Mitchell.Feldman@ucs£edu SSM St. Mary's Health Center
Chapter 4: Difficult Patients/Difficult Situations St. Louis, Missouri
Chapter 11: Families j [email protected]
Chapter 15: Cross-Cultural Communication Chapter 10: Training ofInternational Medical
Chapter 26: Depression Graduates
Chapter 27: Anxiety
Chapter 37: HIV/AIDS Julie Glickstein, MD
Chapter 40: Intimate Partner Violence Professor of Pediatrics
Chapter 49: Trainee Well-Being Columbia University Irving Medical Center
Department of Pediatrics I Division of Pediatric
Sarah Forsberg, PsyD Cardiology
Columbia University Vagelos College ofphysicians
Department of Psychiatry
Weill Institute for Neurosciences and Surgeons
NewYork-Presbyterian Hospital, Morgan Stanley
University of California, San Francisco
Children's Hospital of New York
San Francisco, California
New York, New York
[email protected]
[email protected]
Chapter 23: Eating Disorders
Chapter 47: Narrative Medicine
x I AUTHORS
Deepthiman Gowda, MD, MPH, MS Nellie Hennann, MFA
Assistant Dean for Medical Education Creative Director, Columbia Narrative Medicine
Kaiser Permanente School of Medicine Department of Medical Humanities and Ethics
Pasadena, California Columbia Vagdos College of Physicians and
[email protected] Surgeons
Chapter 47: Narrative Medicine New York, New York
[email protected]
Gillian Graham, MS, PMHNP-BC Chapter 47: Narrative Medicine
Psychiatric Nurse Practitioner
Behavioral Health Network J. Carlo Hojilla; RN, PhD
Northampton, Massachusetts Postdoctoral Fellow, Traineeship in Drug Abuse
[email protected] Treatment and Services Research
Chapter 47: Narrative Medicine Department of Psychiatry
University of California, San Francisco
Richard E. Greene, MD, MHPE, FACP San Francisco, California
Associate Professor, Department of Medicine Carlo.hojilla@ucs£edu
New York University School of Medicine Chapter 24: Unhealthy Alcohol r!r Other Substance Use
New York, New York
[email protected] Eric S. Holmboe, MD
Chapter 17: Lesbian, Ga~ Bisexua4 Transgender, & Chief, Research, Milestones Development and
Q!i.eer Patients Evaluation Officer
Accreditation Council for Graduate Medical
Frederic W. Haffmy, PhD Education
Professor of Medical Education Adjunct Professor, Yale University School of Medicine
Mayo Clinic New Haven, Connecticut
Rochester, Minnesota Adjunct Professor
[email protected] Uniformed Services University of the Health Sciences
Chapter 48: Educating for Professionalism Bethesda, Maryland
Adjunct Professor, Feinberg School of Medicine
Steven R. Hahn, MD Northwestern University
[email protected] Chicago, Illinois
Chapter 11: Families [email protected]
Chapter 43: Competency-Based Education for Behavioral
Frederick M. Hecht, MD Medicine
Professor of Medicine, Division of General Internal
Medicine Eli7.abeth Imbert, MD, MPH
Osher Center for Integrative Medicine Assistant Professor
University of California, San Francisco Division of HIY, Infectious Diseases and Global
San Francisco, California Medicine
[email protected] Department of Medicine
Chapter 35: Integrative Medicine Zuckerberg San Francisco General Hospital
University of California, San Francisco
Stephen G. Henry, MD, MSc San Francisco, California
Associate Professor of Medicine elizabeth.imbert@ucs£edu
University of California, Davis School of Medicine Chapter 37: HIV/AIDS
Sacramento, California
[email protected] Thomas S. Inui, ScM, MD, MACP
Chapter 25: Opioids Director of Research, IU Center for Global Research
Professor of Medicine, IU School of Medicine
Investigator, Regenstrief Institute
Indianapolis, Indiana
[email protected]
Chapter 44: Teaching Behavioral Medicine: Theory r!r
Practice
 AUTHORS I xl

Leah Kalin, MD Ryan Laponis, MD, MS

Geriatric Fellow Associate Professor of Medicine
Oregon Health & Science University University of California, San Francisco
Portland, Oregon San Francisco, California
[email protected] Ryan.Laponis@ucs£edu
Chapter 14: Older Patients Chapter 4: Difficult Patients/Difficult Situations
Chapter 34: Dementia & Delirium
Patrick T. Lee, MD, DTM&H
Sara Kalkboran, MD, MAS Chair of Medicine, North Shore Medical Center
Assistant Professor of Medicine, Harvard Medical Salem, Massachusetts
School [email protected]
Investigator, Tobacco Research and Treatment Center Chapter 8: Global Health and Behavioral Medicine
and Assistant in Medicine
Division of General Internal Medicine, Mack Lipkin, Jr., MD
Massachusetts General Hospital Professor of Medicine
Boston, Massachusetts New York University School of Medicine
[email protected] New York, New York
Chapter 21: Tobacco Use [email protected]
Chapter 1: The Medical Interview
Nicholas Kinder, MSN, APN, AGNP-C
Assistant Professor Debra K. Litzelman, MA, MD
Division of General Internal Medicine & Geriatrics D. Craig Brater Professor of Medicine
Oregon Health & Science University Director of Education and Workforce Development
Portland, Oregon Indiana University Center for Global Health
[email protected] Associate Director of Health Services Research
Chapter 14: Older Patients Regenstrief Institute
Chapter 34: Dementia & Delirium Indianapolis, Indiana
[email protected]
Coleen Kivlahan, MD, MSPH Chapter 44: Teaching Behavioral Medicine:
Executive Director Primary Care Theory & Practice
Professor, Family and Community Medicine
University of California, San Francisco Edward L. Machtinger, MD
San Francisco, California Professor of Medicine
Coleen.Kivlahan@ucs£edu Director, Women's HIV Program
Chapter 41: Trauma University of California, San Francisco
San Francisco, California
Kavitha Kolappa, MD, MPH [email protected]
The Chester M. Pierce, MD Division of Global Chapter41: Trauma
Psychiatry
Department of Psychiatry, Massachusetts General Fclisc Milan, MD
Hospital Professor of Medicine
Boston, Massachusetts Director, Ruth L. Gottesman Clinical Skills Center
[email protected] Director, Introduction to Clinical Medicine Program
Chapter 8: Global Health and Behavioral Medicine Albert Einstein College of Medicine
Bronx, New York
Timothy R. Kreider, MD, PhD [email protected]
Assistant Professor Chapter 45: Assessing Learners & Curricula in the
Department of Psychiatry Behavioral & Social Sciences
Donald and Barbara Zucker School of Medicine at
Hofstra/Northwell
Hempstead, New York
[email protected]
Chapter 30: Personality Disorders
xii I AUTHORS

V11hnu Mohan, MD, MBI, FACP, FAMIA Constance Molino Park, MD, PhD
Associate Professor, OHSU School of Medicine Retired Associate Clinical Professor of Medicine
Department of Medical Informatics and Clinical Columbia University Irving Medical Center
Epidemiology New York, New York
Portland, Oregon [email protected]
[email protected] Chapter 47: Namztive Medicine
Chapter 10: Training ofInternational Medical
Graduates Misa Permn-Bunlic:k, MD, MAS
She Her Hers
Gina Moreno-John, MD Medical Director
Attending Physician and Professor of Medicine Women's Health Center
University of California, San Francisco Medical Zuckerberg San Francisco General
Center Assistant Clinical Professor
Department of General Internal Medicine Department of Obstetrics, Gynecology, and
San Francisco, California Reproductive Sciences
[email protected] University of California, San Francisco
Chapter 40: Intimate Partner Violence San Francisco, California
[email protected]
Diane S. Morse, MD Chapter 16: WOmen
Associate Professor of Psychiatry and Medicine
University of Rochester School of Medicine Stephen D. Persell, MD, MPH
Department of Psychiatry Associate Professor of Medicine, Division of General
Director, Women's Initiative Supporting Health Internal Medicine and Geriatrics
Center for Community Health Director, Center for Primary Care Innovation,
Rochester, New York Institute for Public Health and Medicine
[email protected] Feinberg School of Medicine, Northwestern
Chapter 16: WOmen University
Chicago, Illinois
Danid O'Connell, PhD [email protected]
Training, Coaching and Consultation Chapter 46: Evidence-Based Behavioral Practice
Clinical Instructor, University ofWashington
Seattle, Washington Olesya Pokoma, MD
[email protected] PGY4 Resident Physician, Department of Psychiatry
Chapter 19: Behavior Change University of California, San Francisco
San Francisco, California
Karli Okeson, DO [email protected]
Pediatric Emergency Medicine Fellow Chapter 31: Psychosis
Emory University
Atlanta, Georgia Tl.Dlothy E. Quill, MD, MACP, FAAHPM
[email protected] Professor of Medicine, Psychiatry, Medical
Chapter 32: Sleep Disorders Humanities and Nursing
Palliative Care Division, Department of Medicine
Stevt:n Z. Pantilat, MD University of Rochester School of Medicine
Alan M. Kates and John M. Burnard Endowed Chair Rochester, New York
in Palliative Care timothy_q [email protected]
Director, Palliative Care Program, Division of Chapter 3: Delivering Serious News
Hospital Medicine Chapter 42: Palliative Care, Hospice, & Care ofthe
Department of Medicine Dying
University of California, San Francisco
San Francisco, California
[email protected]
Chapter 38: Pain
 AUTHORS I xiii

Michael W. Rabow, MD Nancy A. Rigotti, MD

Helen Diller Family Chair in Palliative Care Professor of Medicine, Harvard Medical School
Director, the Symptom Management Service Director, Tobacco Research and Treatment Center,
Associate Chief fur Education Massachusetts General Hospital
Division of Palliative Medicine Associate Chief, Division of General Internal
University of California, San Francisco Medicine, Massachusetts General Hospital
San Francisco, California Boston, Massachusetts
Mike.Rabow@ucs£edu [email protected]
Chapter 38: Pain Chapter 21: Tobacco Use

Y. Pritham Raj, MD George W. Saba, PhD

Associate Professor, Associate Program Director
Departments of Internal Medicine & Psychiatry Family and Community Medicine Residency
Oregon Health & Science University Department of Family and Community Medicine
Medical Director, University of California, San Francisco
Emotional Wdlness Center San Francisco General Hospital
Adventist Health Portland San Francisco, California
Portland, Oregon [email protected]
[email protected] Chapter 18: Vulnerable Patients
Chapter 26: Depression
Chapter 29: Somatic Symptom & Related Disorders Em.ma Samelson~Jones, MD
Assistant Clinical Professor
Gita Ramamurthy, MD Department of Psychiatry
Assistant Professor, University of California, San Francisco
Department of Psychiatry and Family Medicine San Francisco, California
SUNY [email protected]
Upstate Medical Center Chapter 31: Psychosis
Syracuse, New York
[email protected] Veronica}. Sancher., PhD
Chapter 6: Practitioner Welt-Being Cerritos College
Department of Psychology
Neda Ratanawongsa, MD, MPH Norwalk, California
Associate Chief Health Informatics Officer fur [email protected]
Ambulatory Services Chapter 20: Patient Adherence
San Francisco Health Network
Associate Professor Derek D. Satte, PhD
Division of General Internal Medicine Professor, Department of Psychiatry
UCSF Center for Vulnerable Populations Weill Institute for Neurosciences
Zuckerberg San Francisco General Hospital University of California, San Francisco
San Francisco, California San Francisco, California
[email protected] Derek.Satre@ucs£edu
Chapter 18: Vulnerable Patients Chapter 24: Unhealthy Alcohol & Other Substance Use

Giuseppe J. Raviola, MD, MPH Jason M. Satterfield, PhD

Assistant Professor of Psychiatry, and Global Health Professor of Medicine
and Social Medicine University of California, San Francisco
Harvard Medical School San Francisco, California
Department of Psychiatry, Massachusetts General [email protected]
Hospital Chapter 27: Anxiety
Boston, Massachusetts Chapter 43: Competency-Based Education for
[email protected] Behavioral Medicine
Chapter 8: Global Health and Behavioral Medicine Chapter 45: Assessing Learners & Curricula in the
Behavioral & Social Sciences
xiv I AUTHORS

Dean Schillinger, MD aiflord Singer, MD

UCSF Professor of Medicine in Residence Chief, Geriatric Mental Health and Neuropsychiatry
Chief, UCSF Division of General Internal Medicine Principal Investigator, Alzheimer's Disease Clinical
Zuckerberg San Francisco General Hospital Trials
Director, Health Communication Research Program Acadia Hospital and Eastern Maine Medical Center
UCSF Center for Vulnerable Populations Bangor, Maine
San Francisco, California [email protected]
[email protected] Chapter 32: Skep Disorders
Chapter 18: Vulnerabk Patients
Gregory T. Smith, PhD
Jason Schneider, MD, FACP Director
Associate Professor, Department of Medicine Progressive Rehabilitation Associates
Emory University School of Medicine Portland, Oregon
Atlanta, Georgia Vancouver, Washington
[email protected] [email protected]
Chapter 17: Lesbian, G~ Bisexual, Transgmder, & Chapter 38: Pain
~eer Patients
Bonnie Spring, PhD, ABPP
Antoinette Schoenthaler, EdD Professor of Preventive Medicine, Psychology, and
Associate Professor of Population Health Public Health
Center for Healthful Behavior Change Director, Institute for Public Health and Medicine-
Division of Health and Behavior Center for Behavior and Health
NYU School of Medicine Co-Program Leader for Cancer Prevention
New York, New York Team Science Director, NUCATS CTSA
[email protected] Northwestern University Feinberg School of
Chapter 1: The Medical Interview Medicine
Chicago, Illinois
H. Rw..dl Searight, PhD, MPH [email protected]
Professor of Psychology Chapter 46: Evidmce-Based Behavioral Practice
Lake Superior State University
Sault Sainte Marie, Michigan Anthony L Suchman, MD
[email protected] Senior Consultant, Relationship Centered Health
Chapter 10: Training ofInternational Medical Care
Graduates Clinical Professor
Chapter 28: Attention Deficit Hyperactivity Disorder University of Rochester School of Medicine and
Dentistry
Taylor Seftrance, BS Rochester, New York
Department of Psychology and Biological Sciences [email protected]
Lake Superior State University Chapter 6: Practitioner Well-Being
Sault Sainte Marie, Michigan
[email protected] Howard L Taras, MD
Chapter 28: Attention Deficit Hyperactivity Disorder Professor of Pediatrics
University of California, San Diego
Ann C. Shah, MD La Jolla, California
Assistant dinical Professor [email protected]
Pain Management Center Chapter 12: Children
Department of Anesthesia and Perioperative Care
University of California, San Francisco
San Francisco, California
[email protected]
Chapter 38: Pain
 AUTHORS I xv

Delphine Taylor, MD John Q. Young, MD, MPP, PhD

Associate Professor of Medicine at Columbia Professor and Vice Chair for Education
University Irving Medicine Center Department of Psychiatry
Columbia University Vagelos College of Physician Donald and Barbara Zucker School of Medicine
and Surgeons Hofstra/Northwell
Columbia University Irving Medical Center Hempstead, New York
New York, New York ][email protected]
[email protected] Chapter 30: Personality Disorders
Chapter 47: Namztive Medicine
Kelly C. Young-Wolff, PhD, MPH
Teresa Villela, MD Research Scientist
Professor and Chief of Family and Community Division of Research
Medicine Kaiser Permanente Nonhern California
UCSF and Zuckerberg San Francisco General Oakland, California
Hospital [email protected]
San Francisco, California Chapter 24: Unhealthy Alcohol & Other
[email protected] Substance Use
Chapter 18: Vulnerable Patients

Judith Walsh, MD, MPH

Professor of Clinical Medicine
University of California, San Francisco
Women's Health Clinical Research Center
University of California, San Francisco
San Francisco, California
Judith.Walsh@ucs£edu
Chapter 16: WOmen
This page intentionally left blank
 Foreword

The heart of health care is the relationship between clinician and patient. What happens in the clinical encounter
substantially affects health outcomes for patients and funilies. Highly effective: encounters amplify the: dlCctiveness
of advances in medical technologies, pharmaceuticals, and systems of healthcare delivery. The quality of this core
relationship also impacts the well-being of clinicians, whose calling to serve in their profession is rooted in a desire to
make a difference in people's lives.
The challenges for clinicians to maintain healing relationships with their patients are enormous. Increasingly,
healthcare professionals are called upon to relate to patients with more diverse lifestyles, cultures, ethnicities, sexual
orientations, gender identities, national origins, economic status, and belien. Intertwined with these social complexi-
ties are the mental health and behavioral problems with which many patients struggle.
&havioral Mdicint: A Guitit far Cuniazl Prtu:tict, now in its 5th edition, gives practitioners useful clinical tools to
address a wide range of patient care challenges. It also provides guidance about how to manage common situations,
such as developing rapport, delivering serious news, or motivating patients to change health-risk behaviors. New
chapters discws the care of patients dealing with trauma or addiction to opioids. This book is also useful to those who
teach behavioral medicine. It indudes topics related to developing an evidence-based curriculum in the behavioral and
social sciences, assessing the competencies of trainees, and educating fur professionalism. These topics are particularly
important in the contat of an ever evolving healthcare system constantly buffeted by change.
One of the significant elements of the book is the recognition that the well-being of health professionals is critically
important to caring for patients. As a profession, we often do not pay sufficient attention to the clinicians, many of
whom become burned out doing the work they love. Chapters on mindful practice and the well-being of practitioners
and trainees enhance the book.
With much nc:w and evidenced-based content, this edition of the book provides insight and information not avail~
able anywhere dse for those who seek to provide holistic, high-quality care fur patients.

~._s"°L­
Eric S. Holmboe, MD MACP FRCP FAoME(hon) FRCPSCanada(hon) CAPT, MC, USNR-R
Chief, Research, Milestone Devdopment and Evaluation Officer
.Accreditation Council fur Graduate Medical Education
Adjunct Professor, Yale University School of Medicine
Adjunct Professor. Uniformed Services University of the Health Sciences
Adjunct Professor, Feinberg School of Medicine at Northwestern UniVt:rsity

xvii
This page intentionally left blank
 Preface

Since the publication of the fourth edition of Behavioral Medicine: A Guide for Clinical Practice, there have been
considerable advances in medical diagnosis and treatment, as well as changes in the ways in which health care is
organized and delivered. The science of genetics has revolutionized the understanding of disease, and we have entered
the era of personalized medicine in which therapies are not only targeted to specillc diseases, but increasingly, to specillc
individuals. New medications, therapies, and technologies are continually emerging for the treatment of a variety of
behavioral health problems, such as mood and anxiety disorders and substance use. Collaborative modds of care for
patients with mental and behavioral disorders have been shown to improve clinical outcomes and are increasingly
being integrated into medical settings. The rapid adoption of electronic medical records as the standard in most treat-
ment settings continues to pose challenges for establishing and maintaining rapport in the clinician-patient relation-
ship. Health care organizations are now compelled to pay greater attention to the importance of clinician well-being
in reducing burnout and error and in maximizing the performance of the organization, including financial outcomes.
This fifth edition addresses these and other new developments in the clinical practice and teaching of behavioral
medicine. Although the term "behavioral medicine" is used widely in both medical and social science literature, there
is little agreement as to its exact definition. We broadly define it as an interdisciplinary field that aims to integrate
the biological and psychosocial perspectives on human behavior and to apply them to the practice of medicine. Our
perspective includes a behavioral approach to somatic disease, the mental disorders as they commonly appear in medi-
cal practice, issues in the clinician-patient relationship, and other important topics that affect the delivery of medical
care, such as motivating behavior change, maximizing adherence to medical treatment, integrative medicine, and care
of the dying.
This edition features important revisions of chapters from the previous editions to reflect advances in pharmaco-
therapy and evidence on the relationship between psychosocial factors and disease. New chapters have been added
to reflect emerging issues in clinical care. For example, with the continued growth of the opioid epidemic, there was
a need for a chapter dedicated to working with patients on these agents. Likewise, the increased recognition of the
importance of trauma and its impact on our patients' health and well-being prompted us to add a chapter dedicated
to that important topic.
Untreated behavioral and mental illness contributes to the global burden of disease, and there are marked dispari-
ties among nations and regions in recognition of these problems and treatment availability. The chapter on global
health and behavioral medicine addresses the cultural and economic determinants of these disparities and offers new
models for behavioral medicine practice and training to reduce the treatment gaps. Health outcomes globally are also
influenced by environmental factors such as climate change, and human behavior is deemed responsible for a growing
stress to the earth and its natural functions. The chapter on environment, health, and behavior examines these inter-
relationships and suggests behavior change models on a societal scale to promote the health of the planet.
The training of physicians and other health professionals has continued to evolve. Greater clarity in defining and
assessing competencies, including that in behavioral medicine, has warranted an extensive expansion of the section
on teaching and assessment with an emphasis on new approaches to training for behavioral competencies. Among
these are more precise descriptions ofbehavioral competencies, advances in evaluation, novel teaching strategies such
as the use of narrative medicine, and evidence-based behavioral practice. Finally, helping trainees in the health profes-
sions to find balance in their lives and to develop the life skills for a sustainable career has challenged medical schools
and residencies to create curricula and educational experiences to promote well-being. These concepts are addressed
in the final chapter of the book.
We hope that general internists, hospitalists, family practitioners, pediatricians, nurse practitioners, physician assis-
tants, pharmacists, and other clinicians will find that this book helps them to better understand and care for persons
with a wide variety of mental and behavioral problems. For residents and students in health care settings, Behavioral
Medicine: A Guide for Clinical Practice can function as a valuable resource for understanding the psychosocial dimen-
sions of medicine.
It is our intent that medical educators will find this book to be a clinically relevant text that forms a basis for
developing a comprehensive curriculum in behavioral medicine. Training in the core competencies required by the
Accreditation Council for Graduate Medical Education (ACGME) will be enhanced by inclusion of topics covered
xix
xx I PREFACE
thoroughly in this book, including clinician-patient communication, professionalism, and cultural competence. For
faculty and students who wish to explore a topic in greater depth, the suggestions for further reading and web-based
resources provided at the end of each chapter will be helpful.
The principles of behavior change discussed in this book apply not only to individuals but also to whole societies as
they move through the "stages of change" to alter lifestyles that adversely impact the environment and human health.
The health and well-being of our personal lives and of the organizations in which we work are intertwined with the
health of our planet. Restoring the proper relationship of humans with the earth in a way that promotes sustainability
in the whole system is what Thomas Berry has called "the great work" of our generation. Physicians and other health
professionals have a vital role to play in this work, for our own health and well-being will only be as good as the health
of the planet.
 Acknowledgments

This book would not have been possible without the support and mentorship of several people. We are forever
indebted to Stephen J. McPhee, MD, for recognizing the need for such a book and for continually providing encour-
agement and advice. Our deep appreciation is offered to Jason Satterfldd, PhD, and to Ryan Laponis, MD, MS, for
their invaluable assistance as associate editors for this edition. We thank Kay Conerly, Kim Davis, James Shanahan,
and Leah Carton at McGraw-Hill fur providing expert guidance, and we are very grateful to our contributing authors
who, despite busy schedules as clinicians, researchers, and educators, have been generous and conscientious in going
the distance with us.
Countless friends and colleagues at our own institutions, as well as the residents we have been privileged to teach
and mentor, have contributed to our own learning and the selection of material fur this book. We are especially
indebted to our colleagues in the Society of General Internal Medicine and the American Academy on Communica-
tion in Healthcare, many of whom have contributed chapters for this book, fur being the learning community that
has helped us grow professionally.
Jane Kramer and Julie Burns Christensen and our children, Nina Mason and Jonathan Kramer-Feldman and Jake
and Hank Christensen, as well as Hank's wife Kerry, Jake's wife Nancy, Nina's husband Adam, and their son Isaac,
have continued to be a renewing and cherished presence in our lives. This book would not have been possible without
their love and suppon.

Mitchell D. Feldman, MD, MPhil, FACP

John F. Christensen, PhD
San Francisco, California and Corbett, Oregon

xx:i
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 SECTION I
The Doctor & Patient
The Medical Interview
Mack Lipkin, Jr., MD & Antoinette Schoenthaler, EdD

INTRODUCTION patients. Physicians with high job satisfaction have a sig-

nillcant interest in the psychosocial aspects of care, relate
The medical interview is both the major medium of effectively with patients, and arc able to manage difficult
patient care and the core care element for patients and patient situations.
practitioners. A successful interview elicits accurate and
complete data. Its dialogue determines whether patients
agree to take a medication, undergo a test, actively par-
The Ubiquitous Interview
ticipate in care, or change their lives. More than 80% of The central role of the interview derives from its epi-
diagnoses are derived from the interview. The doctor- demiology as well as its "one-on-one" impact. For most
patient interaction is the keystone ofpatient satisfaction. physicians, it is more prevalent than any other activity
Interview-related factors impact major outcomes of care, in their work or their lives. The average length of time
including physiologic responses, symptom resolution, per ambulatory patient visit for internists, family practi-
pain control, functional status, propensity to sue in the tioners, and pediatricians is about 20 minutes, and these
event of an adverse outcome, and emotional health. The groups account for 7 5% of doctor visits. The average
medical interview influences the quality of care, includ- visit time for all physicians is 6 minutes, a rate curiously
ing malpractice suits and their resolution; the amount constant in the United States, the United Kingdom, the
of patient disclosure of difficult or stigmatized informa- Netherlands, and elsewhere. Physicians who bring the
tion; time efficiency; and the elimination of"doorknob" average down to 6 minutes are moving scarily fast.
questions at interview's end. Making conservative estimates about how many
Although the interview is a major determinant of hours a practitioner will work over a 40-year professional
professional success, less than 10% of medical practitio- lifetime, a generalist will have around 250,000 patient
ners have spent time since medical school working on encounters. Each interview can be the source of satisfac-
their interviewing ability. When asked, most physicians tion or frustration, of learning or apathy, of efficiency
indicate that they have no plan or approach to moni- or wasted effort, of personal growth and inspiration
toring, maintaining, or improving this critical skill. Can or dispiriting discouragement (Table 1-1). Despite the
you imagine a professional musician, athlete, or pilot importance of performing this complex skill expertly,
not practicing? One would question their commitment, few trainees or physicians plan, or even contemplate,
competence, and chances of remaining successful. how to improve patient encounters to reach the desir-
The interview is also key to each practitioner's sense able goals of satisfaction, learning, and efficiency.
of professional well-being. being the factor that most Each discipline or special interest, such as psychiatry,
influences satisfaction with each encounter. Physicians occupational health, women's health, or domestic vio-
with high career dissatisfaction most often attribute this lence suppon has a specialized set of questions that must
to unsatisfying communication and relationships with be asked of every patient for the interview to be complete

1
2 ICHAPTER1

Table 1-1. Gains from improved interviewing of data is interrupted. The physician can always elabo-
techniques. rate on specific items to round out the data once the
patient's story is spontaneously roughed out and framed.
• Increased efficiency in use of time If the same format is used for each interview, the varia-
• Increased accuracy and completeness of data tions in responses can be attributed to the patient, pro-
• Improved diagnosis viding added insight.
• Fewer tests and procedures The evidence fu.voring a patient-centered approach
• Increased compliance goes beyond the practical advantages: outcomes of care
• Increased physician satisfaction are also improved. More complete and higher-qualiry
• Increased patient satisfaction information-with an attendant reduction in proce-
• Decreased dissatisfaction dures and tests-reduces cost, side effects, and compli-
• Increased mutual learning from each encounter cations. Increased patient adherence to diagnostic and
therapeutic plans leads to greater clinical efficiency and
effectiveness, and patients take a more active role in their
and to elicit that patient's particular problems. (If an own care.
interviewer were to ask every question recommended by
each specialry, the interview would take hours.) In most Efficiency lr Active Listening
cases, these questionnaires have neither been validated
nor shown to be sensitive or specific. Notable exceptions A number of fu.ctors enhance interview efficiency, which
include the CAGE questionnaire (Table 1-2), which is a is increasingly valued as the corporatization, regula-
highly specific, sensitive, and efficient screening test for tion, and digitization of health care cause doctors and
alcoholism (see Chapter 24); the two-question depres- patients to experience medical visits as more rushed and
sion screen (see Chapter 26); and the one-question cramped. Although actual visit lengths have remained
domestic violence screen (see Chapter 40). the same, the tasks to accomplish in a given visit have
Rather than the use of a series of overspeciflc, nar- multiplied-more diseases and risks to evaluate, more
rowly focused questions, it is more effective to use a treatments to choose among and explain, and more
patient-centered approach. First, elicit the patient's computer screens and bureaucratic hoops to negoti-
complete set of concerns and questions. Then explore ate. These trends will undoubtedly prove counterpro-
the prioriry, negotiated problem by asking open- to ductive: when the visit is jammed with too much to
closed-ended cones of questions to encourage elabora- do, psychosocial discussion drops first. The result is in
tion on the information and elicit the needed data about unnecessary testing, patient dissatisfu.ction, and hazard-
each concern. Open-ended questions elicit information ous or needless procedures and treatments. Challenges
more efficiently than lists of closed-ended questions. to efficiency and effectiveness are exacerbated when
A patient-centered approach ensures that the patient's behavioral medicine is removed from the medical visit
concerns are understood and accepted-a predictor of by outsourcing to an external "behavioral management"
increased compliance. Because open-ended questions company. Then both sides compete not to care for the
allow the patient to frame the response, the nature of patient, and predictably the relationship and qualiry of
framing reveals how the patient is processing the issue care deteriorate.
under discussion, information that is unavailable from Specific techniques enhance cost-effectiveness and
closed-ended questions. efficiency. Open-ended questions allow patients to
This approach is efficient for several reasons. First, elaborate on responses, provide additional information,
patients usually have a sense of what is relevant and will and make interviews shorter. "Active listening" involves
include key information and data not thought of by the listening to what is said on multiple levels--how it is
interviewer. A physician who is thinking of the next said; what is included and what is left out; and how what
question rather than listening to what is being said loses is said reflects the person's culture, personality, mental
the abiliry to attend and to listen on multiple levels. If status, affect, conscious and unconscious motivation,
the interviewer is talking and the patient is not, the flow and cognitive sryle. Getting some or all of this provides
layers of time-&ee rich added data. Active listening also
involves acknowledging or repeating the essence of
the information shared, whether clinical or emotional,
Table 1-2. The CAGE questionnaire. which allows the patient to feel understood and to cor-
rect misperceptions. A skilled active listener acquires
C: Have you ever tried to Cut down on your drinking? data quickly and continuously. Like a jazz musician, an
A: Do you feel Annoyed when asked about your drinking? active skilled practitioner creates a harmonious flow in
G: Do you feel Guilty about your drinking? sync with the patient's themes, rhythms, and sryle to
E: Do you ever take an Eye opener in the morning? enhance the abiliry of each to contribute to the complex,
 THE MEDICAL INTERVIEW I 3

shifting improvisation of the interview. The experienced and phone calls, tuning out extraneous sound, elimi-
listener distinguishes his or her observations as clear nating internal distraction and intrusive thoughts by
data, hypotheses, or biases. This creates a complex and resolving not to work on other matters, letting intru-
textured portrait of the patient that can he used in gen- sive thoughts simply pass through your mind for the
erating hypotheses, crafting replies, giving information, moment, and controlling distracting reactions within
managing affective responses and nonverhal hehaviors, the interview by noting them, considering their origins,
and questioning further. and putting them aside.
Such skills do not just happen. We teach our resi-
dents self-hypnosis; practitioners are routinely and effi-
THE STRUCTURE OF THE INTERVIEW ciently able to get to a place of heightened, alert, and
Recent literature on the medical interview runs to more energetic focus. Using this skill together with the sug-
than 50,000 articles, chapters, and hooks. Although gestions in Table 1-4, practitioners can enhance the
only a modest portion of these are derived from empiri- opporwnity for something profound to happen in each
cal swdies, sufficient work has been done to describe the patient encounter.
interview as having "structure" and "functions." Behav-
ioral observations and detailed, reproducible analyses of Observing the Patient
interviews have related specific hehaviors and skills to
both strucwral elements and functions; performance of A great deal can he learned by thoughtfully observing
these hehaviors and skills improves clinical outcomes. the patient's hehavior and body language before and
The following description of essential structural ele- during the encounter. Although initial hehavioral obser-
ments and their associated hehaviors or techniques, vations are purely heuristic-used to generate testable
although comprehensive, is complete yet practical. Key hypotheses about the patient-nonverbal behaviors can
hehaviors are summarized in Table 1-3. One compre- reveal as much about the patient's state of mind as verbal
hensive model of this approach is shown in Figure 1-1. hehavior. Physicians who are unaware of being influ-
enced by initial reactions and observations in the patient
interview may note that when they themselves get on a
Preparing the Physical Environment bus or an airplane, they instantly recognize the person
Architects and designers believe that form follows func- next to whom they would prefer--or not-to sit. Such
tion. Similarly, how practitioners organize their physical responses integrate multiple nonverbal cues. Similar
environment reveals core characteristics of their practice: input from patients relates to their overall health, vital
how they view the importance of the patient's comfort signs, cardiac and pulmonary compensation, neuro-
and ease; how they want to be regarded; and how they as logic and liver function, and more. Observations about
practitioners control their own environment. Does the grooming, state-of-rest, alenness, and style of presen-
patient have a choice of seating? Do both the patient and tation reveal the patient's self-confidence; presence of
provider sit at comparable eye level? Is the room acces- psychosis, depression, or anxiety; chronic disease; per-
sible, quiet, and private? Optimal environments reduce sonality style, culture, or subculture; and important
anxiety and instill calm and a sense of well-being. changes from prior visits. The physician may also detect
signs of possible alcohol or drug use. Esconing patients
Preparing Oneself from the waiting area, letting them walk slightly ahead
into the office, allows the physician to observe gait,
Humans can process 7 hits of information plus or how patients use their waiting time, companions, and
minus 2 simultaneously. Given this, it is advisable to clues to the relationship with companions. Often, espe-
consider how many of these hits are consumed by dis- cially with new patients, the very first words spoken by
tractions or trivia in a clinical encounter. The hypnotic the patient may be epigraphic or may foreshadow the
concept of focus or the recently accepted psychologi- encounter.
cal concepts of centering or flow apply to the clinical Maximizing clinical observation skills starts with the
encounter (see Chapter 5). Thoughts about the last or commitment to do so. Developing the habit of system-
next patient, yesterday's mistake, last night's argument, atically retaining and integrating initial observations
passion, or movie can affect concentration; information will provide the physician with important data typically
and opponunity are lost. In contrast, a focused prac- overlooked. Asking pertinent questions about behav-
titioner, without external or internal distractions, can ioral cues will increase observation speed and compre-
expect the interview to be a challenging, fascinating, hensiveness. Practicing in crowds, at rounds or lectures,
and unique experience. on the airplane, or at parties helps train us to become
Achieving a focused state of mind is personal and more astute observers. It is the physician's equivalent of
related to each situation. Nevertheless, successful cen- practicing scales on the piano or practicing an athletic
tering includes eliminating outside intrusion by beepers stroke.
Table 1-3. Structural elements of the medical interview.

Element Technique or Beh1vlor

------------------------------------------------------------------ -------------- - - - -
Prepare the environment Create a private area.
Eliminate noise and distractions.
Provide comfortable seating at equal eye level.
Provide easy physical access.
Prepare oneself Eliminate distractions and interruptions.
Focus through:
Self-hypnosis
Meditation
Constructive imaging
Let intrusive thoughts pass.
Observe the patient Create a personal list of categories of observation.
Practice in a variety of settings.
Notice physical signs.
Notice patient's presentation and affect
Notice what is said and not said
Greet the patient Create a flexible personal opening.
Introduce oneself.
Check the patient's name and how it is pronou need.
Create a positive social setting.
Begin the interview Explain one's role and purpose.
Check patient's expectations.
Negotiate about differences in perspective.
Be sure your expectations are congruent with patient's expectations.
Detect and overcome barriers to Be aware of and look for potential barriers:
communication Language
Physical impediments such as deafness, delirium
Cultural differences
Psychological obstacles such as shame, fear, and paranoia
Survey problems Develop personal methods to elicit problems.
Ask.what els~ until problems are described.
Negotiate priorities Ask patient for his or her priorities.
State your own priorities.
Establish mutual interests.
Reach agreement on the order of addressing issues.
Develop a narrative thread Develop personal ways of asking patients to tel Itheir story:
When did patient last feel healthy?
Describe entire course of illness.
Describe recent episode or typical episode.
Establish the life context of the patient Use first opportunity to inquire about personal and social details.
Flesh out developmental history.
Learn about patient's support system.
Learn about home, work, neighborhood, and safety issues.
Establish a safety net Memorize complete review of systems.
Review Issues as appropriate to specific problems.
Present findings and options Be succinct.
Ascertain patient's level of understanding and cognitive style.
Ask patient to review and state understanding.
Summarize and check.
Record interview and give copy of recording to patient.
Ask patient's perspectives.
Negotiate plans Involve patient actively.
Agree on what Is feasible.
Respect patient's choices whenever possible.
Close the interview Ask patient to review plans and arrangements.
Schedule next encounter.
Clarify what patient should do in the interim.
Say good-bye.

4
 I Begin inlmiiew I Gather Information
L Snrvey patient'• ftMDDll for the 'l'ilit
Prepare Open a. Start with open-ended, nonfocused quemons
a. Review the patient's chart a. Greet and welcome the patient and family member present b. Invite patient to tell the story chronologically ("narrative thread'')
b. Aasellll and piepare the b. Introduce yourself c. Allow the patient to talk without interrupting
physical environment ........... c. Explain role and orient patient to the flow of the "™t d. Actively listen
i. Optimize comfort and
privacy
ii. Minlllllze intemiptions
...,..... d. Indicllll: lime available and other constraints
e. Identify and minimiz.e barriers to communication
f. Calibrate your language and vocabulary to that of the
+ e. Encourage completion of the statement of all of patient's concerns through
verbal and nonverbal encouragement ("tell me more," the exhaustive
''what else")
patient f. Summarize what you heard. Check for llDdentanding. Invite more
and distractions ("anything more'r')
c. Assess one's own personal
g. Accommodate patient comfort and privacy
II. Determine the patimt'1 dlld concern
ia1111e11, values, biaaes, and a. Ask clOled~ questions that are nonleading and one at a lime
1BSumptions going into the b. Deline the symptom completely
encounter m. CGmplete the patimt'1 mediul databae
a. Obtain medial and family history
b. Elicit pertinent p1ychosocial data
c. SummarU.e what you hem! and how you understand it, check for accuracy

Clome
I Erul interview
a. Signal clo1ure
I
during the entire interview
I. Use relationship buildiac skills
L Allow patient to exprellll self
b. Be attentive and empathic nonverbally
+
EHcit lllld muterstlllld patimt'•
penpective
b. Inquire about any other iames or c. Use appropriate language a. Ask patient about ideas about illness
concerns d. Communicate nonjudgmcntal. i:cspectful, or problem
c. Allow opportunity for final discl08ures and supportive attitude b. Ask patient about expectations
d. Summarize and verify a11essment and e. Accurately recogniz.e emotion and feelings c. Explore beli.efs, conccms, and
plan f. Use PEARLS Slalements {Partnership, expectations
e. Clarify future expectations Empathy, Apology, Respect, d. Ask about family, community, and
f. AllllUre plan for unexpected outcomes Legitimization, Support) to respond to religious or spiritual context
and follow up emotion instead of redirecting or punrning e. Acknowledge and respond to
g. Thank palient----appropriate parting clinical detail patient's concerns, feelings, and
statement 11.Manqellow nonverbal cue1
a. Be organi7.ed and logical f. Acknowledge
b. Manage lime effectively in 1he interview frultralions/challenges/progres1

t (waiting time, uncertainty)

Nqotiate lllld 8Pft on plall

a. Encourage shared decision making to the extent
Patient education
a. Use Ask-Tell-Ask approach to give information meaningfully
-Ask about knowledge, feelings, emotions, reactions, beliefs and expectations
+
Commllllicate dlll'ilJI the phymlcal
eumlnatton or proceclure
the patient desllu -Tell the information clearly and concisely, in small chunks, avoid "doctor a. Prepare patient
b. Survey problems and delineate options babble" b. Consider commenting on
c. Elicit patient's undentanding, concerns, and -Ask repeatedly for patient's understanding aspects and findings of the
preferences b. Use language patient can undecstaIJd physical examination or
d. Arrive at mutually acceptable solution c. Use qualitative data accurately to mhatK:e understanding procedure as it is performed
e. Check patient' 1 willingness and ability to d. Use aids to enhance understanding (diagrams, models, printed material, c. Listen for previously
follow the plan. community resources) unexpressed data about the
f. Identify and enlist resources and supporta e. Encourage quc8tions patient's illness or concerns

•This model ia an expansion of the work of the Kalamaz.oo Consensus Conference held May 1999 supported by Bayer-Fet7.er; in addition other models were consulted directly. These included the
Brown Interview Qlecklist, the Three Function Model, the work of the AAPP Courses Committee-Blue Card, Segue, Calgary-Cambridge Observation Gnide, Bayer model, and an extensive review
of the literature on communications in mOOicine completed for the Macy Initiative. This model has been prepared by the Macy Initiative in Health Communication. Please address questions to
Regina Janicik (212) 263-2304.

Figure 1- f. The medical interview. (Developed by the Macy Initiative in Health Communication.)
6 ICHAPTER1

Table 1-4. Self-hypnotic suggestions to enhance is useful to consider using a f.Urly stereotyped begin-
interview outcomes. ning, such as "what brings you in to see me today?" (As
opposed to " ... how may I help you," which prejudges
In this encounter I will: the purpose of the interview).
Focus on the patient and his or her concerns
Not hear outside distractors Detecting & Overcoming Barriers to
Let intrusive thoughts pass through unheeded Communication
Connect meaningfully with this person
Learn something new and surprising about him or her Many factors that interfere with communication place
Have a positive encounter even more barriers berween the doctor and the patient.
Leave feeling energized Sometimes these are tangible barriers: delirium, demen-
Help the patient grow, change, and heal tia, deafness, aphasia, intoxication (patient or physician),
Help the patient leave the interview feeling hopefu I and or ambient noise. Psychological barriers include depres-
committed sion, anxiety, psychosis, paranoia, and distrust. Social
barriers often involve language; cultural differences; and
fears about immigration status, stigma, cost of the visit,
or legal issues. It is valuable to detect barriers early in
Greeting the Patient
an encounter. Failure to do so not only wastes time but
The greeting serves to identify each person, set the social can seriously and, sometimes, dangerously mislead the
tone, indicate intentions concerning equality or domi- physician. For example, residents and students often
nance, and to prevent mistaken identity. It also allows spend an hour or more trying to extract history from
the practitioner to establish an immediate connection a delirious patient, resulting in an hour lost and highly
with patients, presenting oneself as an open, compe- unreliable historical data. In addition, detecting barriers
tent, compassionate professional the patient can trust. It is the first step toward correction, whether by waiting
enables the physician to learn how patients assert their until delirium or intoxication has cleared, finding a pro-
own identity and how to pronounce their names. Using fessional interpreter or signer, moving to a quiet place,
a standard greeting-saying vinually the same thing or deferring difficult issues until trust is established so
each time-provides data based on the uniqueness of a disclosure is more complete and accurate.
patient's response.
Surveying Problems
Beginning the Interview
Patients come to medical encounters with multiple
The introductory phase of a medical encounter provides problems and, for various reasons, may not lead with the
an opportunity for both parties to express their under- most pressing issue. Physicians typically interrupt very
standing of the purpose and condition of the encounter, quickly (23 seconds on average). It is ofvital importance
to check each other's expectations, and to negotiate dif- not to jump in at the first important-sounding problem,
ferences. For example, the patient may expect to be seen but instead to dicit all problems. For example, the phy-
by the head of the clinic, but the physician is only a sician might ask, "What problems are you having?" or
year out of residency. The patient wants relief from back "What issues would you like to work on today?" After
pain, and the practitioner is worried about the patient's getting the initial answer or series of answers, the physi-
high blood pressure. The cardiologist expects the con- cian can then ask " ... what dse?" again and again until
sultation to lead to cardiac catheterization, whereas the the list of problems is completed and mutual priorities
patient thinks the cardiologist's opinions will be sent to are established.
his primary care physician for a discussion prior to deci-
sion. Perhaps the physician scheduled a 15-minute visit,
but the patient feels an hour is needed.
Negotiating Priorities
One of the best predictors of the outcome of a dyadic Once the physician and the patient clearly understand
relationship is concordance of expectations; therefore, the full set of problems, if the physician then asks,
clarifying and reconciling these is extremely valuable "Which of these would you like to work on first?" and
before proceeding to the main part of the interview. the physician believes that something else is more impor-
The beginning of the interview, especially with a tant than the problem the patient sdects, a negotiation
new patient, sets the interactional tone {although one about this difference can ensue: "Our time is limited
can always change tone by changing one's behavior). today, and I think your shortness of breath is potentially
Although many attempt idle social chat, bland social more dangerous than your back pain. Suppose we deal
questions may confuse the professional focus or make with that first and, if we have time, go on to your back
the patient feel compelled to present a positive tone. It pain. If not, we'll take that up on your next visit."
 THE MEDICAL INTERVIEW I 7

Appropriate and understandable resentment results closed-ended questions tie up loose ends and provide the
when the physician does not ascertain and acknowledge safety of completeness.
the patient's priorities. This can lead to treatment adher-
ence problems or failure to return to the office. Talking During the Physical Examination 8r
Procedures
Developing a Narrative Thread During the physical examination, there is a tension
Once the physician and the patient have decided which between the quiet focusing of the senses needed to
problem has priority, exploration of that problem observe, hear, and fed findings, and mutually necessary
begins. Note the term "exploration." All too often the conversation. Practitioners need their senses of smell,
clinician's approaches are either to jump into a review sight, touch, and hearing to examine the patient. They
of systems ("do you have rectal bleeding ... are your need heightened sensory awareness for the encounter.
gums bleeding . . . ?") or to dicit the seven cardinal fea- Patients need an explanation of what is being done and
tures of the sign or symptom ("where is it, does it radiate, what to expect ("this may hurt"), instruction about what
what makes it better or worse ... ?" and so on). The most to do ("please sit here" ... "bring up your knees" ... "hold
efficient method is to explore the problem by asking the your breath"), and a check on how they are doing and
patient to tdl the story of the problem using an open- responding ("does this hurt?"). The examination often
ended question, as in "Tdl me about your rectal bleed- stimulates the memory of rdevant experiences and prob-
ing." Although many will begin at an appropriate point lems the patient may have forgotten to mention. Some
and move toward the present, some patients may need physicians like to explain what is happening in detail
guidance to begin when the patient last fdt healthy, when ("I am looking in the back of your eye because it is the
the current episode began, or when the patient thinks one place in the body where blood vessels can be seen").
the problem started. The patient may not appreciate the Others do their review of systems during the physical
necessary levd of detail and may be too inclusive or too examination. In general, it is wise to minimize distrac-
superficial. It may be necessary to interrupt to indicate a tions during the physical examination or a procedure by
desire to hear more or less about the problem. Clarify- confining talk to the task and the needs of the patient.
ing questions shows the patient what is needed, and most Explanation of findings can be reserved and are more
patients respond with the appropriate levd of detail. efficient at the end ofthe examination. However, if there
is something big, painful, obvious, or worrisome, com-
Establishing the Life Context of the Patient mon sense may suggest dealing with it in the moment.

Once the narrative thread is established, the physi- Presenting Findings 8r Options
cian can take the opportunity to inquire about specific
points. It is important to respond at the patient's first After the history-taking and physical examination have
mention of psychosocial matters in order to signal to been completed, it is time for the physician and patient
the patient that such matters are as important as bio- to discuss what the problems or probabilities appear to
technical ones. Such inquiries help the physician learn be, rdated findings, the physician's hypotheses or con-
in detail about the context of the patient's life-spouse, clusions, and possible approaches to further diagnostic
family, neighborhood, work, and culture. When enough evaluation and treatment. This should be done in lan-
information has been supplied, simply saying, "You guage free of jargon and at the levd of abstraction the
were saying ... " or "What happened next?" returns the patient understands and uses.
patient to the narrative. This approach works because Bad news includes any information that will change
almost everyone knows how to tell a story and remem- patients from their idealized self-image to a lesser one.
bers key points intrinsically organized by what actually While tdling someone she has diabetes may seem rou-
happened. tine to a jaded practitioner, to a patient who has heard
tough stories about diabetes, or has a relative who died of
it, or is simply a fearful person, it is certainly life-altering
Creating a Safety Net
and might seem disasuous. It is valuable to foreshadow
Once the problems the patient wishes to discuss have any bad or potentially upsetting news (sec Chapter 3).
been explored, areas or questions may remain. For these, This prepares the patient to hear and retain the informa-
the physician may choose to ask a series of specific review tion. It may be useful to suggest the patient bring along a
of systems-type questions. Questions may take the form trusted companion (although this flags the likely news as
of the seven dimensions of a complaint, delineated as bad). When bad news is a certainty, it is useful to record
the location, duration, intensity (use a ten-point scale the explanation and discussion for the patient. These
with zero "no pain at all" and ten "the worst possible days, a digital recorder in the room allows the doctor
pain"), quality, association, radiation, exaccrbants and to provide a copy of the encounter when it ends. The
ameliorants, or a subset of these dimensions. Such final patient can review it after shock has cleared and share it
Discovering Diverse Content Through
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 With 25 full-plates of
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4to, orig. boards,

uncut. Chicago, The
Caxton Club, 1905. (see
illustration, Plate No.
XVII.)

The above is one of a

few special copies, each
of which contains A
GENUINE ORIGINAL
LEAF (contained in a
pocket at end), from a
copy of the First Edition
of Chaucer's
"Canterbury Tales,"
printed by Caxton, and
formerly in Lord
Ashburnham's Library,
having been purchased
for this purpose by the
Caxton Club.

The Author has compiled an extremely interesting Biography of the First

English Printer, avoiding, as far as possible, the merely mechanical
bibliographical details (which have been relegated in an abridged form to an
Appendix), and has confined himself to a more general description of the
Books, especially of those not hitherto correctly or fully described, and is able
to add to the Bibliographical List some discoveries and corrections, since
Blades published his great work in 1861.
 Transcriber's Note

The spelling in parts of this book is from the 15th century, some centuries
before spelling rules existed. The text is as printed.

Sundry missing or damaged punctuation has been repaired.

Both hyphenated and non-hyphenated variants of many words occur in this

book. All have been retained.

Illustrations which interrupted paragraphs have been moved to more

convenient positions between paragraphs, and Index page numbers amended,
if necessary.

Some of the Plates have comments in the margins and/or museum stamps.
Though not always clear, these have been retained, as possibly providing some
further information to the reader.

Page 24: 'plait' corrected to 'plaît'.

"tôt ou tard, s'il plaît à Dieu, sur William Caxton...."

Page 93: '8' corrected to 'a'.

Cordyale fol. 1479

[a-i^8, k^6]; 78 leaves. Leaves 1, 78 blank.

Page 95: 'Ed. 2' added to 2nd entry, as for similar entries above and below.

Lidgate (John). The horse, the sheep and the goose 4to
[a8, b10]; 18 leaves. Leaf 1 blank. [1477]
Lidgate (John). The horse, the sheep and the 4to[1477]
goose. Ed. 2
[a8, b10]; 18 leaves. Leaf 1 blank.

Page 115: 'Somerest' corrected to 'Somerset'.

"Somerset, Margaret, Duchess of, 75"

Index: There were a few page number errors in the Index; these have been
corrected without comment.
*** END OF THE PROJECT GUTENBERG EBOOK WILLIAM CAXTON
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