The practice of medicine is both an art and a science. We are methodical and formulaic when treating disease, but tend to be less so during patient encounters. We tend to be more reactive. We think and act on the fly.
Some visits are more challenging; some go more smoothly. There are a finite number of challenges that we can encounter, and some are more frequent than others, be it a patient who has difficulty giving a history, or one who feels their needs have not been met, despite a diagnosis having been identified and treatment recommended.
For those more common obstacles, why decide how to handle them in the moment; why not have predetermined strategies? We often see the same diagnoses, so we develop ways of explaining things; we should be just as methodical about managing difficult situations.
An easy way to start this formulaic way of approaching the visit is to have a very intentional introduction. I recommend taking a cue from the hospitality industry: thank the patient for coming. Even if we are in high demand and it takes months to get an appointment with us, it is important to acknowledge that we are in a service industry and thus we are grateful that the patient chose us. “Thanks for coming to see me.”
This simple greeting can be said every time and helps start the visit in a positive direction. It can also help if the patient is irate for having waiting a long time, as in, “Thank you for your patience and for coming to see me today.” Patient are often taken aback by this simple statement of thanks and it is particularly important to say this when they have been waiting, so feel like their time is not being valued.
Once the visit gets going, to get an accurate history efficiently, it may be necessary to interrupt the patient. We are taught that we interrupt too soon, giving patients fewer than twenty seconds to speak before being interrupted. We may need to resist our initial urge to interrupt to give them more time than that, but that does not mean that it should be avoided altogether. It is a necessary tool to facilitate storytelling.
When doing this, rather than asking permission, respectfully inform them that you will be interrupting, and then explain why. The explanation is critical so the patient understands that the interruption is being used for clarification and not to dismiss what is being said. “Excuse me, but I am going to need to interrupt you here because I noticed a contradiction in your story. You first described the dizziness as lightheadedness and now you are describing it as room spinning. These are two distinct sensations that can have different causes, and we want to get this right so you can start feeling better.”
Interruption can also be necessary to hear the story in a way that can be processed. Patients often give their histories in order of urgency or severity rather than chronological order, and it can be challenging to process the information that way. If it seems like the patient is time-hopping, this is another instance in which interruption is critical, followed by, “Your time is valuable, and I want to make the most of our time together.
The best way me to understand your story is to hear it in chronological order. And because I want my notes to be accurate, I am going to be typing while we are talking.” Then they know you are taking notes, not checking email, or planning your next vacation.
Patients often require reassurance for things that seem to us mundane. I recently had a scare with a lesion on my back. It looked to me like melanoma. It turns out it was a seborrheic keratosis that had caught on my shirt and formed a scab. I catastrophized the possible outcomes of having a melanoma on my back (we have a family history). I required reassurance, but needed my concerns legitimized.
There is a balance between reassuring and delegitimizing. Using words like “just “or “only” can feel dismissive. Address the gravity of the problem, whether it is genuinely grave or perceived gravity should not matter. Spin it in a way where you exude confidence that it can be handled. For instance, papillary thyroid cancer or squamous cell carcinoma of the skin both have excellent prognoses. However, they are cancer and cancer is scary. Validate the concerns while giving them all the reasons to be hopeful.
Sometimes we get a clear picture of the history, examine the patient, make a diagnosis and are ready to end the visit, but the patient does not seem satisfied, like we have missed something. They get upset, understandably, but to us, it can be surprising and baffling. In this situation, try saying, “I am sorry; I can hear how frustrated you are. I apologize that it is taking me so long to understand.”
Summarize what you have learned from the perspective of their concerns and reflect it back, giving them an opportunity to clarify. “When you lie down and turn to the right, it feels like your head is spinning for a few seconds. It sounds like benign paroxysmal positional vertigo, which was that crystal problem we discussed, but because you have very limited neck mobility, we cannot address it the usual way and you will need to see a physical therapist. Does this address your concerns?”
This gives them an opportunity to voice what may have been missed and close the loop of communication. After asking the question, give plenty of time for silence; a few seconds, and then a few seconds more. This will give them an opportunity to think about why they are upset. There can be a lot of information, piled on top of discomfort and emotions and it may take them some time to process why they are upset.
This type of recap can also help make it clear when the visit has concluded. I have had many occasions when I thought I had made it clear that the visit was over, exit the room, and the patient remains seated, waiting for the visit to end. Prior to the recap, you can set the stage for the close of the visit by saying something like, “before we wrap up, this is what we have covered today…“ Or, “before we wrap up, do you have any last questions for me?“ This is another place the pause is necessary, and again, longer than you would think. Then thank the patient again for coming, closing the visit the way it was opened.
There are many other bumps in the road that prevent patient encounters from running smoothly if we do not have a predetermined strategy for handling them. Hopefully these examples can help you start thinking about what your common hang-ups are and then how to manage them better. This will lead to both a better physician and patient experience.
コメント