Much has been made about physicians’ tendencies to interrupt patients. Studies have shown that patients are permitted 12-18 seconds of talk time before they are redirected (or interrupted) by their doctor. This leads to patients feeling that the physician didn’t listen or didn’t care. I believe that there is a way to solve the problem without wasting time or being rude. I have used this technique with great success over the years and it works especially well in the inpatient setting, when beginning a formal “history and physical exam.” In three simple words:
Physician goes first.
Before I enter the patient’s room, I perform a careful review of their medical records and imagine what it must have been like for them to experience the events leading up to our meeting. I reconstruct the emotional time line in my head and figure out which pieces of information I need to complete my assessment and plan. Then when I meet the patient (often for the first time) I begin by greeting them warmly and then telling them what I have gleaned from their medical records, and how I think they may have felt during the process leading up to their hospitalization. This establishes that I have taken the time to get to know their background, that I genuinely care about how they’ve been dealing with things emotionally, and that I am determined to correct the record if there are any gaps or errors. I then rely on the patient to fill in the details or clarify results that are unclear.
This strategy saves the patient from having to review historical information that the physician already knows about (which usually leads to the classic interruption at second 12-18 of the interaction), and provides structure for patient participation and input. It establishes trust with the new physician, and conveys empathy. It corrects the medical record when necessary, and maximizes the efficiency of the information exchange. To drive home the concept, let me provide you with two hypothetical conversations with “Mrs. Smith” – in the first case the physician will approach her in the traditional manner, and in the second, with the “physician goes first” method.
Establishing the “chief complaint” with Mrs. Smith – Traditional method
Dr. Jones: (entering hospital room where Mrs. Smith is sitting alone in her bed in no acute distress): “Good morning, Mrs. Smith. I’m Dr. Jones, the attending physician for this unit. What brings you here today?”
Mrs. Smith: (eyeing Dr. Jones with some degree of confusion). “Well, I just had surgery, and I guess I’m still a bit weak so they said I needed to come to rehab but I still don’t really understand why I had to change rooms. Did you know I had surgery? Yes, I was walking my dog on the sidewalk and he pulled a little too hard to lurch at a squirrel and the next thing I knew I was on the ground and my hip was hurting and I was all scraped up and I saw this man in the distance who started running towards me and then I think I passed out and when I got to the hospital, I don’t know, they were worried I had a seizure and then they did a CAT scan and then when I….”
Dr. Jones: “I see. But what I need to know from you now is what is your chief complaint. In other words, why are you here in the rehab unit?”
Mrs. Smith: “Well aren’t you the doctor? You’re supposed to tell me what to do when I’m here aren’t you?”
Dr. Jones: “Yes, of course. But I was hoping you could tell me in your own words.”
Mrs. Smith: Sighs heavily. “Well, I’m here because I fell down and broke my hip and then they found out that I hit my head too and then I guess they were trying to figure out if they needed to put a drain in or just give me seizure pills and I’m not sure how they decided but I don’t remember a drain so I guess… Isn’t all this in my records somewhere? Can’t you figure out what happened?”
Dr. Jones: “Yes, it’s all in your chart but…”
Mrs. Smith: “Well then why don’t you just read it instead of asking a poor old lady with a bad headache to tell you what happened all over again. Everyone keeps asking me for the same old story and I’m just so tired…”
Dr. Jones: “So you’re here in rehab because you’re tired?”
Mrs. Smith: “Well, I guess that’s it.”
Establishing the chief complaint with Mrs. Smith – “Physician goes first” method:
Dr. Jones: “Hello Mrs. Smith, I’m Dr. Jones, the rehab physician who will be taking care of you on this floor. I read through your chart very carefully and learned that you fell down on the sidewalk when walking your dog about a week ago. It looks as if you broke your hip as well as hit your head during the fall. I see that you had your hip repaired surgically, and that fortunately you didn’t need any treatment for your head injury because it didn’t bleed very much internally, but as a precaution you were given some anti-seizure medicine. I imagine that this sudden hospitalization was an unwelcome surprise for you – there you were just walking your dog on a normal day, minding your own business and whammo – now you’re here in the hospital with me!? Well, my goal is to get you back home as soon as you’re ready and steady enough. What is your main goal for rehab?”
Mrs. Smith: “Yes, well it certainly was a shock to get the wind knocked out of me. You hear about little old ladies falling down and breaking a hip but I never thought it could happen to me. Now all I need to do is be able to walk safely so I can go home.”
Dr. Jones: “Well, the good news is that you were very active prior to your fall so I bet you’ll do very well here because you have a good baseline fitness level. My goal is to help control your pain so you can make the fastest gains possible. I bet your hip bothers you and you may have headaches too.”
Mrs. Smith: “Yes, well that’s just it. I’m in quite a bit of pain when I stand up but I’m afraid of becoming a drug addict so I try not to take the pills…”
As you can see, the second conversation was much more successful in establishing a relationship with the patient and getting to the meat of what the doctor needs to know (the patient’s primary goal, her pain level, and what the barrier to treatment might be) without the frustration caused by traditional “open ended questions” and lack of structure – leading to interruptions and perceived lack of caring on the part of the physician.
In my experience, doing a little up front chart review and taking the lead in the first patient encounter results in a dramatic decrease in wasted time and need for redirection. So in the case of avoiding rude patient interruptions – taking the conversation lead may be the best bet.
This is an unusual case where putting the patient first involves letting them talk second.