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BECOMING A PHYSICIAN
Common Current Topics and Proposed Comprehensive Topics for the Patient
ed but could, with training, ob-
Social History. tain similar relevant information.
Of course, clinicians should use
Common current topics
their judgment regarding the ap-
Racial or ethnic background
propriate timing of these conver-
Marital status and children
Occupation sations, since patients may need
Highest level of education to establish trust and rapport be-
Tobacco, ethanol, drugs (“TED”) fore sharing intimate information.
Seatbelt and helmet use To obtain proper social histo-
Firearms in the home
Victim of domestic violence
ries, clinicians could be trained
in basic and motivational inter-
Proposed new topics
viewing techniques and chal-
Individual characteristics
Self-defined race or ethnicity
lenged to examine their own bi-
Place of birth or nationality ases, since unexplored prejudices
Primary spoken language influence our ability to obtain or
English literacy act on important information. We
Life experiences (education, job history, military service, traumatic or life-
also recommend that clinicians
shaping experiences)
Gender identification and sexual practices attempt to visit the neighbor-
Leisure activities hoods where the majority of their
Life circumstances patients live, since such experi-
Marital status and children ences can enhance clinicians’ so-
Family structure, obligations, and stresses
cial perspective and help them
Housing environment and safety
Food security understand their patients’ “health
Legal and immigration issues homes.” Such visits might inform
Employment (number of jobs, work hours, stresses or concerns about work) clinicians about people or ser-
Emotional health vices in their patients’ world that
Emotional state and history of mental illness (e.g., depression, anxiety, trauma,
post-traumatic stress disorder)
could be organized to help them
Causes of recent and long-term stress achieve better health and about
Positive or negative social network: individual, family, organizational the forces working against their
Religious affiliation and spiritual beliefs engagement in health-promoting
Perception of health care or harm-reducing behaviors.
Life goals and priorities; ranking of health among other life priorities
Personal sense of health or fears regarding health care In addition to learning how to
Perceived or desired role for health care providers obtain this social information,
Perceptions of medication and medical technology clinicians need to learn how to
Positive or negative health care experiences use it — specifically, they need
Alternative care practices
training in ways of developing
Advance directives for cardiopulmonary resuscitation
Health-related behaviors individualized care plans that
Sense of healthy or unhealthy behaviors take into account patients’ per-
Facilitators of health promotion (e.g., healthy behaviors among close social sonal and structural barriers to
contacts) good health.4 Using shared-deci-
Triggers for harmful behaviors and motivation to change (may be determined
through motivational interviewing)
sion-making techniques and ap-
Diet and exercise habits propriate pedagogical and coun-
Facilitators or barriers to medication adherence seling skills, clinicians can help
Tobacco, alcohol, drug use habits prioritize patients’ goals and em-
Safety precautions: seatbelts, helmets, firearms, street violence power patients to make lasting
Access to and utilization of health care
Health insurance status
changes to achieve self-identified
Medication access and affordability objectives. Increasingly, through
Health literacy and numeracy (may be ascertained with specific tools; e.g., shared-savings contracts and re-
“The Newest Vital Sign”) imbursement for care-coordina-
Barriers to making appointments (e.g., child care, work allowance, affordability
tion activities, clinicians will re-
of copayment, transportation)
ceive financial incentives to make
appropriate referrals to both insti- three subspecialists, and a refer- Attention to the social forces in
tution-based and community- ral to outpatient rehab — and our patients’ lives would allow us
based resources and to commu- has to contend with the eviction to provide better and less costly
nicate effectively with social notice, unpaid utility bills, and care to patients with the most
workers, community health work- isolation that await him at home? complex conditions and situa-
ers, lawyers, therapists, counselors, Trainees could learn how to tions — thereby increasing satis-
and other service providers. assess patients’ literacy and health faction among both patients and
For example, an individualized literacy and how to deliver infor- caregivers. Failure to attend to
care plan for a woman with dia- mation using well-established ped- these forces will perpetuate the
betes might include referrals to a agogical techniques. They could cycle of poor outcomes, high
food pantry and farmer’s market practice motivational interview- costs, and dissatisfaction among
for purchasing fresh produce; re- ing techniques using role playing our neediest patients.
ferral to a community-based walk- and learn, in real clinical set- William Osler said, “The good
ing program, where neighbors tings, how to motivate and em- physician treats the disease; the
help her up and down the stairs; power patients to engage in health- great physician treats the patient
sending prescriptions to a phar- promoting behaviors. Audiotaping who has the disease.” To be able
macy that delivers medication to or videotaping of history taking, to treat the patient, a physician
her home; referral to a medicolegal counseling, and care-planning must ask the right questions and
group for contract assistance con- activities can provide opportuni- know how to act on the answers.
cerning her unsafe housing situ- ties for giving feedback and hon- Disclosure forms provided by the authors
ation; and referral to a commu- ing skills. Clinicians-in-training are available with the full text of this article
nity health center that holds group can be taught how to enhance at NEJM.org.
meetings where she can build re- shared decision making, create
From the Division of Global Health Equity,
lationships, explore new explana- individualized care plans, and Department of Medicine, Brigham and
tory models of disease, and learn work effectively in teams — all Women’s Hospital (H.L.B., J.J.R.), the Divi-
from others’ stories of illness and principles that we believe should sion of Infectious Diseases and the Medical
Practice Evaluation Center, Department of
coping. For the most challenging be incorporated into the U.S. Medicine, Massachusetts General Hospital
“nonadherent” patients, a struc- Medical Licensing Examination5 (P.K.D.), and Harvard Medical School
tured home visit by medical team and the Accreditation Council for (H.L.B., P.K.D., J.J.R.) — all in Boston.
hospitalization with new prescrip- clinicians who provide more per- DOI: 10.1056/NEJMp1404846
tions, orders to follow up with sonalized and appropriate care. Copyright © 2014 Massachusetts Medical Society.