During at least one of your encounters, you are likely to find a patient who smokes, drinks, or has another habit that may adversely affect his or her health. Although these behaviors may or may not be relevant to your primary diagnosis, it is important that they be addressed in a rapid yet caring manner. Here are some examples of conversations you might have with your patient. Try to practice saying some of these aloud, making sure to change them to fit your personality and style.
The Smoker
Examinee: Do you smoke cigarettes?
SP: Yes, I have smoked one pack a day for 20 years.
Examinee: Have you ever tried to quit?
SP: Yes, but it never works.
Examinee: Well, I strongly recommend that you quit smoking. Smoking is a major cause of cancer and heart disease. Are you interested in trying to quit now?
SP1: Yes. (If the answer is “no,” see below.)
Examinee: I would be happy to help you quit smoking. We have many tools to help you do that, and I will be with you every step of the way. Let’s set up an appointment for two weeks from today, and we can get started on it then. Is that okay with you? SP2: No, I don’t want to quit.
Examinee: I understand that you aren’t ready to quit smoking yet, but I want to assure you that whenever you are ready, I will be here to help you.
The Alcoholic
Examinee: How many drinks do you have in a week?
SP: It is hard to say. Too many.
Examinee: How many drinks do you have per day?
SP: Oh, maybe five or so.
Examinee: Have you ever felt the need to cut down on your drinking? Have you ever felt annoyed by criticism of your drinking? Have you ever felt guilty about drinking? Have you ever had to take a morning eye opener? (In general, any patient who admits to many drinks per week should receive the CAGE questionnaire. A “yes” answer to any one of the questions in the CAGE questionnaire should raise suspicion and prompt further questioning.) SP: All of these things apply.
Examinee: I am concerned about your drinking. It can lead to liver disease, cause problems with bleeding, or even predispose you to early dementia. Are you interested in cutting down or quitting?
SP1: Yes. (If the answer is “no,” see below.)
Examinee: I am glad you want to quit. A variety of resources are available to help you quit drinking, and I would like to discuss them with you. Let’s make an appointment later this week to talk about your options. In the meantime, I have printed up a list of resources, and my office assistant will bring it to you.
SP2: No, I am not ready to quit.
Examinee: I realize that you are not ready to quit drinking, but I want to assure you that if you do decide to try, I will be here for you. Okay?
The Patient with Uncontrolled Diabetes
Examinee: According to your blood glucose readings, your diabetes is not adequately controlled. How often do you forget to take your medication? (Check for noncompliance.)
SP1: Taking all these medications just gets so confusing. I can never remember when to take them.
Examinee: Diabetes can certainly be a challenge to manage. Do you have someone who could help you take your medications? If not, we have a social worker who might be able to arrange for a nurse to come to your home. Are you interested in that? SP2: I have been taking my medications exactly as they were prescribed to me.
Examinee: Tell me about your diet. (Check for dietary management.)
SP2: I eat regular meals, but I really like to drink soda. Diet soda tastes awful!
Examinee: You must be very careful about your sugar consumption. It is prudent to keep your blood sugar within normal limits. Persistently high blood sugar can cause damage to your eyes, kidneys, and nerves. You will also be at higher risk for developing infections, heart attacks, and strokes. Fortunately, we have a diabetes educator who may be able to help you. Are you interested in meeting with her?
The Sexually Promiscuous Patient
Examinee: Are you currently in a sexual relationship?
SP: Yes.
Examinee: Can you tell me about your partner or partners?
SP: I have a girlfriend, but I also see a couple of other women on the side. Examinee: Are you using any type of protection with these partners?
SP: My girlfriend is on the pill, but I don’t use anything with the other women I see. Examinee: Condoms reduce the risk of sexually transmitted infections. Do you think you could try to use condoms?
SP: I tried them, but I just don’t like them.
Examinee: I understand that you may not like to use condoms, but I am concerned that you may be putting yourself and your partners at risk for STDs. You could contract HIV, herpes, chlamydia, or any of a number of other STDs. The complications of these diseases include infertility, painful infections, or even death. If anyone with whom you have sexual contact has an STD, you could share it among all of them, including your girlfriend. I hope you will consider using a condom in the future. Do you have any questions for me?
The Depressed Patient
Examinee: Do you have problems sleeping? Have you lost interest in things that used to interest you? Do you feel guilty? Do you lack your usual energy? Has it been difficult for you to concentrate? Has your appetite changed? Have you felt agitated or lethargic? (Psychomotor disturbances.) Do you feel as though you want to hurt yourself or someone else or commit suicide? (If you suspect depression, ask the questions posed in the mnemonic SIG E CAPS.)
SP: (Answers affirmatively to many of these questions.)
Examinee: You answered “yes” to many of my questions. I believe that you may be depressed. Depression is a common disease; it is due to a chemical imbalance in the brain that causes many of the symptoms you have described to me. Fortunately, we have medications that can help; however, these medications work best when they are combined with counseling. I can write you a prescription and also give you a referral to see a therapist. Is this something you are interested in?
The Patient with an STD (Trichomoniasis)
Examinee: Your symptoms are due to an infection called trichomoniasis, a sexually transmitted infection that has been given to you by one of your sexual partners. This infection responds well to treatment with antibiotics and is curable. You will also need to be tested for all other STDs. Your partner needs to be informed and treated as well; otherwise you will be at risk of contracting the infection again. Unless you use condoms, you should avoid sexual intercourse until you finish the course of antibiotics and your partner gets treated.