Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 4.

Another lesson in the informal curriculum is how to interrupt patients.[1. The skill of interrupting is also useful for unfocused patient presentations, preoccupied nurses, and rambling doctors.]

Due to financial challenges in the healthcare system, patients and physicians have decreasing amounts of time with each other. Doctors need specific information for an accurate diagnosis, which guides appropriate treatment. Sometimes patients want to share information that they believe to be important, but it may not be clinically relevant.[2. Physicians should take care: Sometimes the information that patients find important is, in fact, relevant, though we may not initially recognize this.] Confusion and frustration result when patients view their information as both important and relevant, while doctor finds the information to be neither important nor relevant.

When medical students learn to interview patients, they often nod, smile, and exhibit body language that tacitly encourages patients to continue, even if patients are sharing anecdotes about a recent vacation. Afterwards, when I ask students for their opinions about their interviews, they often express disappointment.

“I didn’t get the information I needed. But I didn’t want to interrupt because I didn’t want to be rude. It seemed like that the patient really wanted to talk about her vacation.”

Two points to consider:

Firstly, though the dialogue between patient and doctor may seem to follow the rules of a usual conversation, the clinical interview is not a normal social interaction.

Do you routinely ask your friends or family if they are are experiencing side effects from medications? if they are having regular menstrual cycles? if they’re thinking about killing themselves? if they’re passing gas?

Such questions rarely come up in usual social interactions. Imagine how other people might react if you asked these questions during a dinner date, while waiting in line at the grocery store, or in an elevator.

Context matters.

Secondly, consider short-term versus long-term goals. Physicians don’t want to be rude to patients. Building and maintaining rapport is important in clinical care. However, patients (often reluctantly!) see physicians to receive guidance and treatment for their health. These are not friendships. If you require history to arrive at a diagnosis and treatment and you are unable to get that information, then you are not actually helping the patient. It may feel better in the short-term to let patients share irrelevant information, but, in the long-term, the health of patients will not change.

So, what are some ways to interrupt people while minimizing rudeness?

The vast majority of patients understand that time with their physicians is limited. Patients who talk a lot often know that they talk a lot. Orienting patients to the possibility of interruptions before starting can be extraordinarily helpful if the need arises.

All human beings want acknowledgment that you heard and understood what they said. I often counsel medical students to jump in when they can (when the patient takes a breath, when the patient is trailing off, etc.) and briefly summarize the last few things the patient said, and then append a question. Example:

“… she always says it’s my fault and I never do anything right and she only says that when things don’t go the way she wants them to and she never sees all the things I do right and when I point them out she thinks I’m being arrogant but I’m just trying to point out that I do some things right most of the time—”

“You get upset when your girlfriend doesn’t see how hard you try—how have your blood sugars been?”

Bonus points if you can tie the summary sentence to your question (e.g. “With all of that frustration you’ve felt with your girlfriend, have you noticed if it has affected your blood sugars?”).

This strategy requires your full attention. If your summary statement is completely inaccurate, your patient will feel vexed.

Other strategies, with increasing urgency (always done with respect):

  1. Say the person’s name (most people will stop talking).
  2. Lean forward and express urgency on your face.
  3. Make some other sound (e.g. firmly putting your hand on a table) in addition to saying the person’s name and leaning forward.

Never raise your voice or shout.

I advise students to try different methods of interruption with friends, family, and classmates, and ask them to gauge what seems to work, what doesn’t seem to work, and how people respond. These experiments serve both as practice for interrupting people in general, but also shapes behavior to interrupt with grace and tact.