Copious Documentation

On Thursday I had my first full history and physical examination with a standardized patient! This proved a really great way to learn. The standardized patients are trained to present with a particular disease, and so the elements of the history and physical all match up to point towards a diagnosis that we have studied, and should know. Our patient (we worked in pairs) likely had angina.

Anyway, the whole experience on Thursday lasted about 40 mins. What blows me away today, is that I’ve just spent more than three hours writing up the case report! Granted that I am an amateur, it is still unbelievable how much documentation is required after every clinical encounter. The results of all questions and tests are recorded, and any that were missed are noted as not having been assessed. Some of my slowness may have been due to that our tutors require us to write out the case reports by hand, as this is more comparable to how they would be done in a hospital.

Standardized Patients

Today I saw my first patient! Sort of. 

What actually happens in medical school is that they hire actors and actresses to come in and fill the role of a “Standardized Patient” (SP). The patients are trained to present to us with a particular medical problem, and then to provide us with feedback on our care. It’s a great way to learn because it exposes students to seemingly real medical problems, without jeopardizing the treatment of real patients. Additionally, the SPs give fantastic feedback, which you might never receive from a real patient.

Actor or not, seeing a patient for the first time is terrifying ! I was really nervous! You want to make sure to properly address the patient’s needs and get all of the relevant information from them, all the while maintaining their comfort and trust.

Here’s some things that I found difficult:

• Thinking of which question to ask next, while still listening carefully to the answer from the last one
• Knowing when I have enough information; realizing when to end the interview
• Maintaining attentive eye contact without staring
• Expressing empathy in words, as well as body language and facial expression
• Avoiding gap-fillers like “ok” and “alright” – particularly when whatever the patient has just told you is in no way ok, or alright.
• Having nothing to offer the patient yet, with my two weeks of medical training!

So I certainly have a lot to be thinking about, and working on, with regards to my communication skills. But these are crucial skills to becoming a good doctor.

Word Choice

Thursdays (tomorrow) are clinical skills days, which means that we all dress up like doctors and try out our skills at interviewing patients. In preparatory reading for tomorrow, I learned something cool and new:

The individual words that we choose to communicate with are very important! Much of the time, I think I opperate under the principle that as long as my overall message is accurate, the individual words that I use to convey that message don’t matter much. Evidence has shown that that’s not the case.

For example, a particular study done with pediatricians, their patients, and their patients’ moms found that one specific word choice impacted how the moms answered questions. (Reference for this study to be added soon). When asked “What are you worried about?” the moms were likely to respond with “I’m not worried!”. However, when they were asked “What are you concerned about?”, almost every one had an answer that illuminated information surrounding their child’s health. That single word choice made such a difference!

Another example, is the word “should”, which carries immense power. When used carefully, it is forceful and compelling. But it also has the potential to turn people off, due to its aggressive, critical nature.

To become a good clinician, it will be important to be very concious about word choice and how different words are percieved. What are some of the words that you find to hold power?

Needling for Information

Part of my registration at Queen’s requires ensuring that my vaccinations are up-to-date. I also need blood work to prove that I have immunity to the communicable diseases that I may be exposed to in a hospital environment. All of this amounted to being jabbed repeatedly.

But it also generated an amusing encounter, raising the question of how a health professional should ask a patient for sensitive information. One of the tests required was for HIV. As my family doctor was filling out a requisition form, his pen drifted over a section where risk categories should be identified. These could include being sexually active or taking injected drugs. A brief pause. The pen faltered, before moving on to the next section. Finally about a minute later, he turned to me asking (Irish accent required) “have you got a girlfriend, then?”. No, I answered,… and he left it at that.

How do doctors ask sensitive questions? A direct, unashamed approach relies on trust within the doctor-patient relationship, while needling gently around the edges may illicit more honest responses. What to ask, and how to ask it? Respect for privacy may allow medically important clues to remain hidden. On the other hand, requesting personal information that is not absolutely necessary is invasive and can warrant an official complaint.

As we learn interview skills in first year, I hope to hear from the professionals what they have learned about asking personal questions.