Category: Medicine

Another recommendation in the informal curriculum is to regularly acknowledge patient strengths.

Physicians are specifically trained to look for problems. The purpose of diagnosis is to identify what is wrong with a patient’s health. As a consequence, we spend a lot of time thinking and talking about what is ill, incorrect, out of order, defective. Our worldview can shift so that we overlook what is healthy, robust, flourishing, hopeful.

Patients, like all people, like to hear what they are doing well. None of us like the experience of receiving only negative feedback, particularly when we are doing the best that we can. Acknowledging patient strengths explicitly recognizes the contributions patients make towards improving their health. We want them to continue to do those beneficial things.

Physicians are in positions of authority and power. Taking the time to comment on what a patient is doing well can strengthen the relationship between patient and physician. Furthermore, this positive feedback can encourage patients to continue their efforts in improving or maintaining their health status. (Positive reinforcement[1. Positive reinforcement is an active intervention that increases the likelihood that a specific event will happen. Example: A woman wears an orange blouse to work. People tell her that the orange blouse looks great on her (intervention). As a result, she wears the blouse more often.] is often more effective than negative reinforcement[2. Negative reinforcement is the removal of something unpleasant that increases the likelihood that a specific event will happen. Example: A woman wears a green blouse to work. People incessantly whine that she looks better in an orange blouse. She wants the whining to stop (i.e. removal of something unpleasant). As a result, she might wear an orange blouse more often.] or punishment[3. Punishment is an active intervention that is meant to increase the likelihood that a behavior will stop. Example: A woman wears a green blouse to work. People spit at her because she is wearing that blouse. She learns not to wear the green blouse… but note that she does not know what the desired behavior is. Compare this with negative reinforcement.] in changing behavior.)

Acknowledging patient strengths need not be saccharine. Simple observations can serve as encouragement:

• You’re checking your blood sugars regularly.
• I see you’ve gotten out of bed three times already today.
• You’re keeping a record of how much alcohol you’re drinking.

These observations may ostensibly appear neutral. However, patients know that doctors pay attention to those things that we find important. This attention is often highly valued currency. Patients may find themselves attending to and doing these desired behaviors more often as a result.

How often do you explicitly point out what people are doing well? Do you find yourself commenting more on problems?

1. ”Tell me what you think helped keep your blood sugars within this healthy range on this day.” or “A lot of your blood sugars are too high.”
2. ”You’ve helped your body recover by getting out of bed.” or “You should get out of bed more often.”
3. ”What’s helped you limit your alcohol use to a bottle of wine on that night?” or “On most nights you’re still drinking two bottles of wine. This is a problem.”

Of course, there are occasions when we must discuss problems and focus on what is wrong. This is not a call to willfully disregard what is out of order. This is a reminder to balance what we say.

And lest these suggestions seem foolish, consider your own experiences with your supervisors. We like it when people recognize and praise the work that we do. It’s a drag when we only hear about our lack of productivity, patient complaints, or the urgency to discharge patients from the hospital. Most people want recognition and encouragement for their efforts.

Patients are no different.

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.

My third recommendation for the informal curriculum about interviewing patients: Respond in the moment to what patients say and do.[1. There are instances when it is prudent to withhold or alter responses. Further discussions about this require an introduction to learning theory. If you want to learn more, please see Pryor’s Don’t Shoot the Dog to learn about reinforcement and how to use that on animals… including humans.] Patients tell physicians information that is difficult to talk about or rarely discussed. If William Osler was correct in advising, “Listen to your patient, he is telling you the diagnosis,” then you must clearly communicate to the patient that you are listening, so he can continue to tell you the diagnosis. The way you respond to patients will affect the amount of information patients will choose to share with you.

You do not need to say a word to respond to patients. A nod can encourage patients to continue with details. A smile can reinforce decisions to change health behaviors. Furrowed brows can express concern. Putting down the pen or stopping the typing can highlight your wish to help the patient. Do you know the color of your patient’s eyes? Taking the second to do that will help you attend to the person in front of you.

Your responses can be utterances. All of those sounds we make that aren’t words can be helpful. The “mm hmm”, “hmm…”, and “huh” take less than a second to utter and tell your patient that you’re listening to them. Example:

I’ve had this pain in my right side for about two weeks. (mm hm) Sometimes it gets really bad and it’s hard to breathe. (hmm) I thought I strained a muscle at first, but it’s just getting worse. (huh)

Patients will let you know if you’re uttering too much: They will abruptly stop talking because they think you’re trying to say something; they will look perplexed; they will ask you if you’re okay. And, full circle: Respond to what patients say and do. Tone down the utterances.

Your responses can also be words. A patient dislocated her shoulder and she feels great pain. She’s wincing, but otherwise quiet. Possible responses:

• “Shoulder dislocations are really painful.” (acknowledges the pain associated with shoulder dislocations)
• “Thank you for your patience throughout all of this.” (acknowledges her pain and your appreciation that she is cooperating as best as she can)
• “How is the pain now?” (responding to the wince)

All of these responses, verbal or not, tell your patient that you are paying attention. We are not in an age (yet) where computers can provide accurate empathy and validation. Algorithms and technology have their place in medicine as treatments; physicians, as people, can provide care. Patients are grateful for care. It is care that acknowledges and respects their humanity, in sickness or in health. This is why people still consult human beings with medical degrees after an exhaustive search on Google.

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.