PATIENT INTERVIEW GUIDELINES FOR DOCTORS #9

WHAT MEDICAL TEXTBOOKS DON’T TEACH YOU ABOUT BEING A DOCTOR | PATIENT INTERVIEW

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Inspired by: What great basketball coaches can teach us about doctoring  

Kevin MD, a prominent voice in the medical social scene, recently wrote an illuminating article on the lessons doctors can glean from basketball coaches. This eloquently written article highlights the rudimentary qualities required for success in basketball, medicine and quite possibly any other realm of life. The fundamental recipe for excellence, evidently, is consistent across various disciplines. Doctors are renowned for being reticent when it comes to the medical world and prefer to aggregate in their ultra-specialized and limited circles, often patronizing even the sister specialties. Research has consistently revealed the numerous advantages of positive social interaction with the well-versed of every social stratum.

Going back to fundamentals

John Wooden certainly made an impression when he started his list of advice with, “how to put on your socks”. Surely a team of grown men had at least that much of knowledge in the two plus decades spent roaming the Earth. It should rightfully come second nature to them, as it should to all other childhood graduates. Interestingly, the tendency to overlook the ordinary is the reason stressing about it is essential. We rarely pay meticulous attention to the routine tasks of life and, quite rightly so since even the little decision-making processes consume vast amounts of energy and fuel that is better reserved for more fruitful endeavors. In a fact, experts advice that a daily predictable and unambiguous routine boosts productivity considerably by unloading the responsibility of the mundane decisions of every day. Therefore, one has to be astute in recognizing those particular routine tasks that add exponential value to the physician experience and toss aside the truly unremarkable.

In the case of the socks, it just so happens to be a crucial aspect. Players spend a gargantuan amount of time in their socks and shoes. A wrinkled pair of sock can easily cause blisters and much dreaded and unnecessary pain. A well trained and physically robust athlete may be crippled by an inadequate foot-gear. The value of the years of training could regrettably become meaningless in the face of defeat by an Achille’s Heel.

Similarly, doctors spend years acquiring knowledge and displaying the relevant technical competence required to pass the numerous board exams. Somewhere along the journey, the soft skills of people interaction and basic human etiquette begin to take a back seat. Ultimately, doctors have to remind themselves repeatedly that the patient is their focus. The patient is at the centre of all measures of competence and excellence in this profession. The patient is not a knowledgeable professor watching the resident do a procedure or history taking process for the thousandth time. The patient is a human being who is currently afraid and unsure of what the confusing array of symptoms imply. Here are some steps doctors can take to earn the patient’s confidence and be not only a brilliant, but also a credible doctor.

Thou Shall Obey these Fifteen Rules

1The physician should always review the charts before the encounter. This small step circumvents episodes of embarrassingly visible frenzy over piles of paperwork in front of the patient. Remember the patient is entrusting the healthcare practitioner with the most precious commodity he has, which is his life. The healthcare community has a duty to preserve this sacred trust.

2Practice good social etiquette. Always knock before entering and acknowledge everyone in the room, which includes all family members and caregivers. The diagnostic process commences as soon as the physician appears within noticeable distance. You should start by introducing yourself, greeting the patient by last name, making consistent eye contact, shaking hands firmly, and smiling. Be aware of any assistance the patient may need immediately and offer a helping hand.

3Dress appropriately, which includes a clean and neat white coat with your badge and name clearly visible, identifying you as a member of the healthcare team. Patients expect a well-groomed physician. Casual attire or blatant disregard of appearance may indicate condescension.

4It is preferred to address patients by their last names and the corresponding titles such as Mr., Mrs., Dr. and Ms. An exception should only be made for patients who are adolescents or younger. Do not use terms such as, “Honey”, “dear” or “grandpa”. A formal address emphasizes and maintains the professional nature of this encounter. Ask the patient to correct you if you are unsure of the pronunciation of their names.

5Certain scenarios require sensitive handling of the situation.

A. The patient is having a meal: Ask whether you can return when he or she has finished eating
B.The patient is using a urinal or bedpan: Allow privacy. Do not begin an interview in this setting.
C.The patient has a visitor: You may inquire whether the patient wishes the visitor to stay. Do not assume that the visitor is a family member. Allow the patient to introduce the person to you.

6Be attentive to the physical surroundings. The physical setting in which you are conducting your interview may be an aid or a hindrance. The ideal setting should be quiet, well-lit and private. This need may conflict with the limited resources of your hospital where sometimes four patients are crammed into one room, making one-on-one human interactions a challenge. Try to make the best of the situation. If you are not given a separate room, position yourself and the patient in a way that creates an artificial private area. Draw curtains around the patient’s bed to establish privacy and minimize distractions. If it is feasible, gently request the neighboring patient’s radio or television to b turned down. Adjustments of lights and window shades should be done to eliminated excessive glare or shade. Adjust the patient’s bedlight to a comfortable level; the patient should not feel as though they are being interrogated.

7The emphasis should always be on patient comfort. Be attentive to patients who may be dependent on a variety of simple tools such as eyeglasses, hearing aids and dentures. Do not overlook these simple objects as they play a significant role in the patient’s perception of their quality of life and comfort.

8A neat little trick learned from experience is to use the stethoscope as a hearing aid for the hearing-impaired patients. Place the ear piece in the ears of the patient and speak into the diaphragm like a microphone.

9Make provisions for the individual preference of position. The patient may either sit up on a chair, lie flat on the bed or lie at an inclined angle, the exact value of which may be sporadically adjusted. Certain procedures may require the patient to be at a specific position and a precise angle of inclination. Remember that the patient’s discomfort or pain takes precedence over inconsequential nitty gritty medical technicalities. However, if a position is strictly required for accurate measurement or diagnosis, this matter is to be gently explained to the patient. Nonetheless, patient discomfort is to be minimised as much as possible using the help of pharmaceuticals if necessary. These steps may seem overindulgent and superfluous. After all, you as the physician, endure long work hours on your feet and accept it as a necessary and inclusive package of life that every human being has to endure for progress. Why should the patient be any different? These steps are, however, not unreasonable or extreme. You will be glad for it when you reap the immense benefits of a satisfied and appreciative patient, thrilled by your sincere compassion and concern.

10Traditionally, the patient and the physician is to be seated comfortably at the same level (excluding cases of immobile patients). There is also the option to positioning the patient at a higher level than the physician. The visual advantage increases the likelihood of the patient opening up during the course of the interview. Whatever the respective positions, the physician and patient should always be comfortably situated directly facing each other, making full eye contact.

11It is unbefitting of the physician to sit too close to the patient or sit on the bedside of the patient. Even if the patient welcomes the gesture, physicians should not take advantage of the vulnerable circumstance of the patient and maintain a distance of at least 3 to 4 feet. This distance follows the Goldilock’s principle of being “just right”. Distances greater than five feet is too impersonal, and distances closer than three feet may interfere with the patient’s private space.

12Body language and non-verbal communication is a separate topic by itself, which shall be discussed in another blog post. For now, remember to appear welcoming and friendly. Do not cross your arms as that projects an attitude of superiority and instantly causes the patient to adopt a distant and non-personal attitude, making it difficult to obtain the crucial information you need in the history.

13If the patient happens to be bedridden, avoid standing tall over the patient. Bend down and lean forward to make communications easier. Remember to lower the bed rail so that it does not become a barrier in the interaction. Remember to also put the bed rail back up upon the conclusion of the session.

14Be considerate of the modesty of the patient at all times. Ensure that the patient is appropriately draped and only the required areas are exposed for the apt duration of time needed for the completion of the examination. Be professional in your conduct and respect the patient.

15Patients are surprisingly perceptive to your level of authenticity and genuine interest in them as more than just a vehicle of disease. If the patient is not seriously ill, it is advisable to establish rapport by opening the conversation with a light-hearted and non-medical related question before you begin any diagnostic questioning. This puts the patient at ease and facilitates the smooth progression into clinical history taking.

SOLVE: THE CASE OF THE PECULIAR ICED TEA

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A 56-year old man consulted a physician at a hospital in May 2014 for thesymptoms of generalized weakness, fatigue and body aches.

His serum creatinine levels were found to be elevated (4.5 mg per deciliter[400 μmol per liter]). Review of his past medical history indicated previous creatinine levels of 1.2 mg per deciliter (110 μmol per liter) in October 2013 and 2.5 mg per deciliter (220 μmol per liter) in February 2014.

His lab results did not detect any proteinuria or hematuria. The urine sediment was remarkable for the presence of abundant calcium oxalatecrystals.

He did not have a personal or family history of kidney stones or other renal ailments. He did not report occasions of ethylene glycol consumption and he had no malabsorptive symptoms. He did not undergo any gastric surgery. The only unusual aspect detected in the history was the regular drinking of 16 8-oz glasses of iced tea. This had not been documented to cause any significant medical problems previously.

The patient’s renal failure worsened rapidly and uremic symptoms were seen. This state of affairs necessitated the initiation of dialysis.

Despite the rapidly progressive nature of the patient’s renal failure, kidney size remained normal on ultrasonography.

A renal biopsy was perfomed.

QUESTION:

WHAT do you reckon was observed in the renal biopsy?
WHAT is your diagnosis?
WHAT was the cause of the occurrence?