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All photos are accurate. None of them is the truth. Richard Avedon

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Clinical Examples (1)

Collaborative work with patients necessitates understanding how important communication style is when the clinician is attempting to learn about the patient and the patient’s illness. 

 

Index: 

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  • I walk into an exam room to see a patient of one of my partners. The name is only vaguely familiar and the face, not at all. “Good morning, Mr Jones. I’m Doctor Elias. You usually see Dr. Rifkin, right?” (He nods.) “He isn’t here today but I had an opening. Let’s see if I can measure up.” (Eye contact and smile during this while I’m logging into Centricity.) “The computer says you’re here for a cough, but I’d much rather have you tell me what your concerns are.” (Comments: Enough energy to distract from computer, explanation of my role, reinforce his relationship with PCP, empower him by putting my performance on the line, diminishing the role of the computer, give him open-ended opportunity to state his REAL concerns. Compare with walking in, “I’m Dr Elias. How long have you had the cough?”)
  • Mr. Spate arrived at 9:05 for a 9:00 (20 minute) appointment for change/worsening in migraine, so I am starting at 9:12 (that soon because I have the world’s best nurse). After the greeting, “Before we get started on your migraine, are there other things you were hoping to address today?” (I’m already less open-ended than usual, narrowing the scope to his migraine, instead of asking what his concerns are, but I’m acknowledging it obliquely, and soliciting other issues prophylactically.) If he says yes and lists several concerns: “Those are too important to try to squeeze in today. We wouldn’t be able to do a good job. (Writing a note on the encounter form directing the front to schedule another appointment.) We’ll set aside some time in the next week so we can address them properly. Now, tell me what’s going on with your headaches.” 
  • As part of the HPI, it is important to ask not only about the symptoms, but about the patient’s response: What have you tried?  How did that work? How did that feel? How was that for you? What made you decide to call? What bothers you the most about what’s going on? (This avoids offering treatments that have already failed. It can also give clues about what has been partly effective. And it can elicit information about the patient’s frame, resources, approaches to symptoms.)
  • The List Bearer.  Mr. and Mrs. Bradbury arrive for his physical, with a list of issues and questions. You know it won’t be possible to address his health maintenance needs, assess his several chronic illnesses, and address all their issues. “I see you have a list of concerns. That’s great. It will help us make sure we don’t miss anything. We may not have time do address them all this morning, because we also have to review your diabetes and heart failure and talk about some preventive measures you are due for. If we don’t get to them all, the list will help us know how much additional time to schedule. Which one would you like to start with?” (Acknowledging the validity of the concerns and the value of the list, setting a framework for what the visit will cover, and giving the patient the ability to make sure a couple key concerns are addressed.)

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