Part 2/2 can be read here.
In today’s article, I’ll be discussing how to use the subjective interview to ask questions about the pillars of health. I’ll also provide education handouts that can be downloaded below.
I believe that the pillars of health can be divided into 5 broad categories – movement, sleep, nutrition, stress-management and human connection will give us our biggest return on investment. These pillars act as leverage points, which are places where we can intervene in order to create significant change across the entire system (1). We have the innate ability to heal ourselves if we give care to these areas. This does not contradict the utility of Western Medicine; instead, it provides a broader view that respects our ability to self-regulate.
We should aim to focus on limiting factors when possible, which are the inputs into a system that prevent more of a desired activity. When we are unable to identify limiting factors, restoring variability should be our primary goal. For example, health is expressed through movement variability, heart rate variability and psychological flexibility.
The Power of the Subjective Interview
A lot of useful information can be acquired during the subjective interview. As the saying goes: if you listen long enough, the patient will tell you what their issue is.
From a clinical perspective, the subjective interview is an opportunity to hear the patient’s story. It helps us gain a biopsychosocial understanding of their primary complaint; and allows us to identify key findings and behaviors that may be limiting. In addition, subjective markers can be used as outcome measures in order to track progress. A thorough interview will help develop a working hypothesis, which can be confirmed in the objective exam.
The main questions we want to answer are:
What do we need to accomplish for you to feel your rehab has been successful?
What is meaningful to you? What activities would you love to get back to?
Where relevant, I’ll ask questions about the pillars of health so I can identify possible interventions. For example:
Movement: what does your current training program look like? Exercise selection? Frequency? Volume? Any dramatic spikes in frequency or volume?
Sleep: tell me about the quality and quantity of your sleep. What is your pre-bedtime routine? How long does it take for you to fall asleep? How many times do you wake up throughout the night? What is your energy level in the morning from 0-10?
Nutrition: tell me about a typical day of eating. Do you have any allergens or sensitivities? Do you ever feel bloated or have achy joints after eating certain foods? Do certain foods give you indigestion or diarrhea?
Stress-management: have there been any particularly stressful life events in the past year? Tell me about your stress management strategies.
Human connection: tell me about your social support network. Do you have people that you can rely on during times of need?
HOW I USE THESE HANDOUTS
Lets say the subjective interview has identified limiting behaviors that are relevant to the patient’s pain. This is a perfect opportunity to discuss how better decisions can lead to better health outcomes. I’ll use the handouts below to help convey the message, combined with analogies, drawings and other recommended resources. Of course, we must work within our scope of practice and refer to other professionals when appropriate. I am not a Psychologist or a Dietitian, but I believe it’s our duty to have a basic understanding of these pillars. Education in these areas can also be incredibly impactful when applied appropriately. Please click on the links below to download these one-pagers for your use:
The details of these handouts may give some patients the impression that they need to do everything on the sheet. This couldn’t be further from the truth. I often use a highlighter to emphasize a few points as I elaborate on the concept in conversation. This helps to make the information stick through combining visual, verbal and written forms of learning. I also emphasize that they don’t need to do everything listed – it’s there for additional information if they find it interesting.
Some people won’t be receptive to this type of information and that’s okay. We need to meet the patient where they are at and find places to compromise so that they can be successful.
Next week, I’ll be exploring behavior change and motivational interviewing in relation to the above topics. Please subscribe to my newsletter to get notified of future posts!
References:
1. Meadows D, Wright D. Thinking in systems. White River Junction, Vermont: Chelsea Green Publishing; 2015.
