Behavioral Science

180 Deja Review: Behavioral Science
What is the cone method of
interviewing, or “coning”?
Starting with an open-ended question,
then progressively narrowing down to
more specific close-ended questions.
CLINICAL VIGNETTES
A 79-year-old woman came into the hospital complaining of shortness of breath.
After an extensive workup, you find that she has metastatic lung cancer. Her son
finds you in the hallway and states “In our culture our elders do not like to know
about serious illnesses. It is my duty as a son to take care of my mother.” You are
unclear about what cultural practices are appropriate to the patient. How do you
approach this situation?
It may very well be that there is a cultural aspect to discussions of terminal illness
that is appropriate to consider in this case. If available in your institution, a “cultural
consult” may be appropriate with someone more versed than you in these issues. If
not, it would be inappropriate to withhold information based solely on what the son
of the patient says. The best case would be to sit down with the patient and ask her
about her cultural beliefs around illness—“Some members of your culture prefer
not to talk about their illnesses, but instead allow their children to make medical
decisions for them. How do you feel about the discussion of illness?”
A patient with known sickle cell disease comes into the ER. He states he is in 10/10
pain and requests 15 mg of morphine. The nurse says he is a “frequent flier” and
worries that he is an addict. He doesn’t look like he’s is in any pain. What should
you do?
Treat his pain. With known disease it is more important that he does not suffer
than to distinguish his symptoms from malingering. Remember, sickle cell crisis
can be extremely painful even without outward signs of pain.
You call a family meeting for a chronically ill patient whom you just found out has
leukemia. Everyone is comfortably sitting in your office. What do you say next?
“What do you know about your illness?” It is important to be open-ended and see
what the patient’s thoughts are. Most likely he has been thinking about this much
more than you and probably is very well informed; or he may have completely
unrealistic views that would be good to learn about before the conversation. Probe
a bit to understand this, and then to ascertain how much he wants to know before
delivering the news.