Asking the right questions: Taking a behavior history (Proceedings)

The goal of this presentation is to improve history taking skills which are necessary for examination and creating a behavior problem list. Communication skills as well as knowledge about how and what to ask during an appointment are discussed. Specific questions vary depending on what type of problem will be addressed; however, the general framework provided in this presentation will allow a clinician to create a complete behavior problem list.

History taking

Taking a history from a client is a necessary skill for any practicing veterinarian, whether you are a specialist, or not. Specifically within behavioral medicine, compiling a complete history and detailing the results of behavioral observations are the main aspects for reaching a conclusion. Hence, a large portion of any behavior appointment is dedicated to getting the complete history. A good history will allow the practitioner to identify all the problems, continue on the path to create a list of differentials, which will eventually lead to the road that takes the clinician to the destination – the diagnosis, hopefully. History taking skills require communication skills as well as knowledge about what to ask and how to ask it. Not only, but especially within behavior medicine, asking the right question or asking the question in the right way will help tremendously in reaching a diagnosis, because fancy diagnostic tests are not (yet) available to the veterinary behaviorist. Most veterinary behaviorists require the clients to fill out a lengthy history form (example: https://www.sfspca.org/behavior-training/behavior-consultations) and will review them prior to meeting with the client and the patient to save on appointment time. This process also helps greatly for asking specific questions in order to arrive at a diagnosis more efficiently. The goal of this presentation is to lead the practitioner to the path of a behavior diagnosis with the treatment as an outcome goal.

A: Opening

Introduce yourself. Chances are the client knows who they are coming to see; however, it is good “bed-side manners” to introduce yourself first and explain to the client how the appointment will be structured. You are setting the expectations from the start.

Signalment: Identify your patient: age, breed, and weight are important data and can affect your differentials, diagnosis and/or your prognosis.

B: Exploration

Presenting complaint (PC)

This is what the client tells you is wrong with the patient.

History of presenting complaint (HPC)

Gain as much information you can about the specific complaint(s).

• Determine trigger(s) that elicit the behavior(s): try to be as specific as possible, (e.g. a large male wearing a hat and carrying a garbage bag coming from the front)

• Determine the threshold: at what level does the behavior NOT occur? This is just as important as at what level the behavior does occur. Clients will often tell you the behavior happens “all the time” or “unpredictably”; it is your job to ask the questions to determine the situations or circumstances as to when the behavior does or does not occur. Open ended questions are preferred in the beginning stages of an interview as not to “lead” the client.

• Body language: the description of the body language before, during, and after the behavior problem occurs is very important. This information can be provided by verbal description from the client, observation of a video and/or pictures as well as by direct observation. However, aggressive incidents do not need to be “reenacted”.  In most cases it would be unsafe and irresponsible to do so and it is not needed in order to develop a problem list or a list of differentials.

Past medical history (PMH)

Gather information about the patients other medical problems (if any) and vaccine history. Past or concurrent medical problems can directly affect your problem list, differentials and diagnosis.

Drug history (DH)

Find out what medications the patient had been taking in the past or is currently taking, including dosage and how often they are taking them e.g. once-a-day, twice-a-day, etc. including any OTC, herbal, homeopathic or other products which have or have not worked for the patient. Past or concurrent medications can directly affect your differentials and your treatment plan.

Find out if the patient has any food restrictions or other allergies.

Family history (FH)

Gather some information about the patients and the family's daily routine such as feeding schedule, sleeping location, exercise. 

Training history (TH)

This is the opportunity to find out a bit more about the patient's training background.  What commands and tricks can the patient do and what training methods were used to train. The use of confrontational techniques used in the past can directly affect your differentials and diagnosis.

C. Summary of history

Complete your history by reviewing what the client has told you. Repeat back the important points which lead you to creating your problem list, so that the client can correct you if there are any misunderstandings or item missing. This does not mean that you will be addressing each and every problem in your initial appointment but it does allow you to discuss priorities of the problems. Often the priorities of the client and the priorities of the severity of the problems are not the same and the client needs to be educated. By summarizing the important points you will be able to find any discrepancies and will avoid non-compliance, or even frustration.

Review the client's goals and expectations for the consultation. It is often a good idea to ask what the precipitating event for this consultation is. Many problems have been ongoing for years and a change in environment, routine or social events might elicit the consult with specific needs for the client. A good acronym for this is ICE - Ideas, Concerns and Expectations.

Patient questions/feedback

During or after taking the history, encourage the client to ask any questions they may have.

D. Closing

When you are satisfied that you have all of the information you require in order to complete your problem list and reach a diagnosis, you will summarize your assessment and explain your diagnosis. You will discuss the steps of the treatment plan. You must consider the safety issues and recognize the client's limitations (emotional, environmental, financial, time restrictions, other family member's views). Client's compliance, or lack thereof, should be acknowledged and understood, otherwise might lead to frustration of everybody involved. A client that fully understands all aspects of the treatment plan has increased chances for compliance. You need to set expectations and a schedule for any required recheck visits.  Thank the client for their time and encourage them to follow up with you with any questions or concerns. I tell my clients that I assume “No news is good news”!