Category: Observations

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.