Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 2.

An “informal curriculum” refers to lessons that are not explicitly taught. In medicine, there are skills doctors learn that are rarely recorded in textbooks or overtly discussed during rounds or lectures. However, these are important skills that doctors need so they can work effectively with patients and colleagues. Lessons in the informal curriculum include how to present patient information to other doctors, how to discuss end of life care with the families of patients, etc.

Contrast this with the “formal curriculum”, which focuses on topics such as anatomy, physiology, and using the language of the field. Contrast this also with the “hidden curriculum”, which can include topics like how to hide medical errors, beliefs about the utility (or lack thereof) of different types of physicians, etc.

In this series, I will share some lessons from the informal curriculum about interviewing patients.[1. Back when I was a medical student, psychiatrists were still considered the artisans of the clinical interview… and not just dispensers of psychiatric medications.] I usually teach these lessons to medical students. Other physicians, psychiatrists or not, may find them useful. If for nothing else, this provides an opportunity for all of us to consider how physicians can improve interactions with patients.

I am purposely omitting the first recommendation for now because it is paramount, the most difficult to define, and often challenging to implement.

My second recommendation: Orient patients to the interview. Patients often don’t know what to expect during an initial visit with a doctor. It takes less than 60 seconds to explain the ground rules of the game of the clinical interview. Doing this can help dispel some of the anxiety patients may have about the meeting. It also gives physicians the opportunity to shape the interview before it begins.

Make introductions. Tell people your name. Ask patients for their name (and how they would prefer to be addressed). Though a power differential exists between doctor and patient, you’re both human beings. Good manners go a long way in building a strong working relationship. The person in front of you is not just a patient: He is a person with hobbies, strengths that you may not have, and a name. Acknowledge the person and at least learn his name.

Tell patients how much time you have together. In outpatient settings, most patients generally know how long appointments will last. In inpatient settings, the schedule is less clear. In both locations, however, patients may have expectations that you will spend much more time with them than you actually can. Explicitly announcing the amount of time available can help establish and maintain focus on the presenting problem.

Tell patients what will happen during the interview. You don’t have to present a detailed itinerary, but do give patients a general idea of what to expect. If you’ll be asking a lot of questions, say so. If you’ll be performing a procedure, explain what will happen. People generally don’t like surprises. Do your best to give patients enough information so they can prepare themselves for what’s next.

Tell patients that you might interrupt them. Sometimes, some patients may start telling you things that they think you want to know. Sometimes, this information is irrelevant. Because you only have limited time together and you may need information that patients may not think to tell you, tell patients that you might interrupt them before you ever do.

When I first meet patients, my preamble goes something like this:

Hi. My name is Dr. Yang and I work as a psychiatrist. We have about 45 minutes together. I’ll be asking you a lot of questions, some of which might make you wonder, “Why is she asking me that?” If you find me interrupting you, I’m not trying to be rude; I just want to make sure I get the right information.

It takes less than 30 seconds to say that. As a result, however, I have essentially let the patient know:

  1. We have time together, but it is limited. We’ll both try to stay focused on your concerns.
  2. You might find some of my questions weird. Humor me.
  3. I intend to be courteous, but I might be impolite because I might need information that you may not think to tell me.

Without this orientation, patients might end up telling me unnecessary information. They might feel vexed when I start asking questions they don’t expect (like when I ask about menstrual cycles, HIV status, or where they live). They might find my manner rude if I interrupt them to stay on track.

This is expectation management. And this can be one of the more important things we can do for patients.