Explanation, Planning and Closing: ED Medical Interview (Part III)

This is the last part of medical interview. Again, this is when you need to display strong communication skills. As a beginner I often used to skip this step until I started looking  things from "the patient's perspective". In my opinion, this is the major difference in terms of how medicine is practised in developing countries, in contrast to the developed world. 

This is where I prefer to sit and talk to the patients at least for a few minutes. A busy ED cannot be an excuse for not doing this. Patients expect us to have a conversation with them at the end of the interview hoping to get an understanding and possible explanations of their problems. 

This could also be the most important piece of conversation if you are planning to send them home, good (written+verbal) discharge instructions can save you as well as your patient. 

EXPLANATION

Assess their current understanding

By now you should have some idea of where the symptoms are coming from. Assess the patients understanding and ask them what to they believe/ think about the origin of their symptoms (if you have not asked them already). If they come up with a medical diagnosis, ask them how much do they know about it. This is important to know before you explain them about an illness. Don't waste time explaining the very basics of diabetes mellitus to someone who googled it just prior to the visit!!

Diagnosis/ Differentials

In the ED, reaching a diagnosis is not always possible. Few patients understand this while other might not. Your job then becomes to tell them the possibilities and say that we are going to deal with the life threats first and other trivial problems can be dealt later. Now I have come across situations when patients didn't like this statement of only "ruling only the life threats". Don't loose your cool. Many of them may not be aware how systems work in the ED. Give them some time and avoid rushing through these issues because this often leads to patient dissatisfaction. Giving them a few extra seconds to digest the info here will go a long way. 

Learning how to reassure them comes with time. If you can't explain the occurrence of a particular symptom, be honest and accept that rather than trying to explain using medical jargon! 

Google/Youtube

It varies depending on where you practise, the kind of background from where your patients come from. Use resources to show images, pictures and short videos to help patients understand the pathology better. Give them resources from where they can read more about it and I promise they will tell you something new about their illness next time!

Timelines

Whenever you want them to wait for something, set a timeline. Say if you are sending labs, give them a timeline on turn around times. If CBC takes 1 hour to come, tell them its going to take 90 minutes. If you promise 60 minutes and get back after 90 minutes, patient is not gonna be happy. If CT is going to take 15 minutes, say 30 minutes. (Always under promise and over deliver). 

PLANNING AND CLOSING

Ask their opinion and do Shared Decision Making

Whenever there is an option to choose from, tell them the pros and cons and let them choose. Guide them, help them but avoid imposing your advice onto the patients. Unless you answer the "WHY" question for them, they are not going to stick to the advise. Tell them why something is important, benefits of following and possible harms of being non-compliant. 
Here in India, we frequently come across patients who are not comfortable making any sort of decisions by themselves and want the physician to weigh the pros and  and the cons, and make the best decision for them. It is fine as long as they are made aware of the all the possible options and alternatives. 

Discharge and Safety Netting 

Importance of spending the last few minutes with a patient cannot be emphasised enough. This is probably what they are going to remember out of the visit today. They are going to recall and use this info before they visit you next time for a similar ailment and also might pass on this to friends/family!!

Explain them what you thought initially about their symptoms, how you excluded things based on history/labs/probability and what you are finally left with. Some patients like this info to be short while others look for in depth details. 

It is okay not to reach a diagnosis at the end of an ED visit. Sometimes reaching a diagnosis takes days or weeks. What is expected from us is not to miss the life threats and acute pathologies. (Most patients appreciate and understand this)

Talking about Meds: How it works? How it is taken? What to expect while on medication? What to do/not to do when on meds? (With no medical jargon!)

Red flags - When to come back? Be explicit on this. 

We are here 24x7x365, please feel free to come back if you ever feel something is not right. Also provide with ED contact number in case..

Having a symptom specific discharge advice saves time - You can have printed advise sheets for common problems like mild head injury, diarrhoea, flu etc. Patients can read this then you can reinforce on this. 

Given them written + oral advice to cut down the confusion. They can read it as many times as they want. Don't fall into the trap on providing only oral instructions. ED attendances are often unexpected, chaotic, people are distressed. Don't overload them with info.

Further concerns and questions

This is the last question that you should be asking them before closing. It once again checks if we have missed anything or if they have something left unattended. This makes them feel reassured and cared for. 

Emergency Medicine is tough. People come to us when there is nobody else to help them out. They might not like us (and would like to see their family physician) 

As emergency healthcare providers, we are not their choice but their fate!

Reaching out to their expectations at this point is something we all should strive for and this is what makes EM special.

Gathering Info: ED Medical Interview (Part II)

This part forms the core of the interview. In the ED, this should take about 10-15 minutes typically.

1) Encourage patients to tell the story: Give them about a minute without any interruptions. Within a minute you will have a good idea about their chief complaint. If there are too many chief complaints then ask them what is bothering them the most and focus on that complaint. Often there are 2/3/4 chief complaints and then you need to prioritise them and set them in order. Of course we all come across patients who take us all over the map, do not lose your patience with them and very gently bring them back to the track. It is important to use words like we/us/together rather than I/me/you during the conversation.

What brings you here today?

How are you doing?

2) Use open ended questions first: It is recommended to start with an open ended question in the beggining and set them free to express symptoms and concerns. If they miss something important then use closed ended questions to clarify your doubts and best some specific info. As you actively listen to them, make neutral utterances and give them non-verbal cues to encourage them to tell more. If you ask a specific question, give them a few seconds to think. Avoid giving them a list of options to pick up one, unless they are unable to explain. If you come across a guy with shoulder pain for 6 years and now he is in the ED, it is important to ask about the triggers that made him come to the ED. 

Say: Tell me more about the chest pain (open-ended)

How long you have been having this pain (closed-ended)

Don't say: Is the pain burning, heavy, sharp? 

Avoid giving them a list of options.

3) Be attentive, sensitive, supportive

As they are telling you their story, listen attentively, facilitate the process if they have issues with something. Body language (speech, expressions, voice tone) and non-verbal cues play a major role here. Once again, if you are taking notes as you are talking to them, make frequent eye contact. Give them non-verbal cues, pick up their verbal and non-verbal cues. If you are not clear about something, paraphrase that and clarify. Acknowledge their agony. When talking about sensitive issues, once again ask for their permission.

Say: I can imagine how difficult it is.

So you are saying that the pain started around the umbilicus and then moved to the lower abdomen. Is that right?

4) No Jargon
Despite out best efforts to stay away from it, we still use jargon. It is best not to use medical jargon during the interview. The way you communicate can be gauged with the educational status/ occupation of individual patients. What I do is, I tell them beforehand that I will try my best to avoid using medical jargon, if there is anything they are free to interrupt and ask me.
Patients might think that they will sound stupid if they ask a question or if they ask us the exact meaning of a word (say Resuscitation). Therefore, it is recommended to avoid jargon as far as possible.

Say: I am going to ask you a few questions regarding the chest pain to find out exactly what is happening. I will try my best not to use any medical jargon, in case I do that unknowingly, please feel free and interrupt me. Is that okay?

5) Understand their perspective and don't be judgemental
Understand how patients look at an illness and what are their beliefs. Sometimes they tell us the diagnosis right away. Nevertheless it is important to always work with an open mindset, when you are doing the work up (because patients with meningitis can have SAH too!). Few key questions that can provide us invaluable info are:

• What are you concerned about? (highlights the chief complain again)
• What do you think is the reason for the knee pain? (Tells us about their beliefs or sometimes "the diagnosis")
• Is there anything else that you think I should know? (Often this question gives us the most important piece of history)

6) Summarise and check accuracy
When you are done with the history, present a brief summary to them to make sure that you got it right or if they want to add anything to it. Don't overdo this. Just a 15-30 seconds summary to check the accuracy of the history.

So, you have got this chest pain that has bothered you a couple of times during the last week. It comes on exertion and gets better when you rest. Do you want to add anything? 

Key points for gathering info:

• Start with open ended questions and then get specific with close ended questions
• Be attentive, sensitive and supportive 
• Ask for the triggers
• Avoid using medical jargon 
• Understand the patient's perspective and don't be judgemental 

William Osler: Listen to the patient, he is telling you the diagnosis

The first 60 seconds - ED medical interview (Part I)

As physicians, we encounter a variety of individuals everyday. Establishing relationships and building a rapport with people is something that we all should be expert at. These communication skills are undoubtedly crucial to gather the right information, ensure patient comfort and better patient care, but these skills represent one of the most overlooked aspects of medicine at least in this part of the world. 

Learning how to do a "medical interview" takes time. It is a process that is learned over years where we try to quickly develop a supporting relationship, gather information and offer information at the same time. 

We are going to cover this in three parts:

Part I: Initiating the session (First 60-seconds)
Part II: Gathering Information 
Part III: Explanation, Planning and the Closing the session

Initiating the Session (The first 60 seconds)

The first few minutes that we spend with the patients sets the foundation for the interview as well as for our relationship with them.  

1. Welcome 

• Appearance: Patients find cleanliness, conservative dress and name tag reassuring. Always have your ID displayed.
• Hand Hygiene (No excuse for this!)
• Greeting: Shaking hands is fine but be sensitive and look for the non-verbal cues because cross gender hand shakes are considered inappropriate in some cultures. At the same time, keep a watch on the non-verbal cues like facial expressions, posture, body language (throughout the interview). Remember that the patient is also observing you and reading your nonverbal cues. So be attentive, maintain a good eye contact, smile, be polite and respectful. Demonstrate your concern and make them feel important. 

If the family is around, be sure to acknowledge and greet each one of them, enquiring their names and relationship with the patient. (Maintain confidentiality when family is around). Ask the family respectfully, to leave before you start the interview unless the patient  wants them to stay.

2. Using the patient’s name

Some patients like to be addressed by their first name when they are greeted; but others prefer either their last name. So it is always better to be formal to start with (Use Mr./Mrs. or Ms. if you do not know a woman’s marital status) and address them using their last name in your initial greeting. After formally greeting the patient, ask how do they prefer to be addressed and use the preferred title/name the next time. It is easier to go from more formal to less formal terms of address than the reverse. If the patient's name sounds unusual to you, then ask them how to pronounce it.

"I am afraid of mispronouncing your name. Could you say it for me?" Then repeat their name.

3. Introduce your self and identify specific role

Use both your first and last names when introducing yourself. Avoid saying, “Hey Philip, I’m Dr. Chandy” or “Welcome Mr. Philip, I’m John.”  
After you introduce yourself, mention your official role, for example, "attending, resident or medical student”. Occasionally at the beginning but more often after some time, a relationship on first-name basis may develop.

"Mr. Philip.. Hello, I’m Dr. John Chandy. I’m the resident physician here who will be looking after you. How do you prefer to be called?"

4. Ensure patient readiness and privacy

Be courteous, make sure they are ready for it before you start the interview. Once ready, then you can ensure privacy by shutting the door, pulling a curtain (with their permission) around the hospital bed or respectfully excusing the family members. 

5. Remove Barriers to Communication
Make every possible effort to remove the barriers that hinder communication. When dealing with elderly, they should be able to see the your mouth in order to speech-read. If there is any question, ask the patient whether she or he can hear you well. Patients experience that you have spent more time with them if you sit, so do so whenever possible. Communication is optimal if you and the patient are at the same eye level. Attention to the nonverbal aspects of communication is important. 

If possible, Avoid taking notes when you are doing the history. At times, we do need to take the notes for comprehensive documentation. When doing this, do make some eye-contact and put down your pen intermittently.  

6. Ensure comfort and put the patient at ease 

These efforts are always worth the time  Determine if anything at the immediate time is interfering with the patient’s comfort. Questions like, “Are you comfortable?” or “Is the light bothering your eyes?” or “Can I raise the head of the bed for you?” are essential. Take their permission before you start the interview. Pay constant attention to patient’s comfort as you proceed. Show your care, compassion and concern. In short, treat them the way you would like to treated!!

Engaging in a little social conversation is another good way to put the patient at ease (if they are stable and have a minor illness). This breaks the ice and allows the patient to get more comfortable with you. 

If you are ever in any doubts, step into the patient's shoes and you will almost always come up with the right answer!!

Stay tuned for Part II: "Gathering information" that forms the core of the interaction.

References:

1. http://onlinelibrary.wiley.com/store/10.1046/j.1525-1497.12.s2.7.x/asset/j.1525-1497.12.s2.7.x.pdf;jsessionid=64F85FD04AEF5D03A8946EC4B3BC025D.f03t01?v=1&t=igywaxdv&s=ec03fdf5028bee52b6da44a9918f90683ceaa79f
2. Makoul,G.,A.Zick,andM.Green,An evidence-based perspective on greetings in medi- cal encounters. Arch. Intern. Med., 2007; 167(11): 1172–1176.
3. Frankel,R.M.andT.Stein,Getting the most out of the clinical encounter: the four habits model. J. Med. Pract. Manage., 2001; 16(4): 184–191.
4. Kahn, M.W., Etiquette-based medicine. N. Engl. J. Med., 2008; 358(19): 1988–1989. 
5. Mast, M.S., On the importance of nonverbal communication in the physician-patient interaction. Patient Education & Counseling., 2007; 67(3): 315–318.
6. Roter, D.L., et al., The expression of emotion through nonverbal behavior in medicalvisits. Mechanisms and outcomes. J. Gen. Intern. Med., 2006; 21(Suppl 1): S28–S34.
7. Gladwell,M.,Blink:The power of thinking withoutt hinking,1 the dition.2005, New York: Little, Brown and Company.
8. Frankel, R. and T. Stein, Getting the most out of the clinical encounter: the four habits model. Permanente Journal., 1999; 3(3): 79–92.

Towards a better EM Residency: Resident Welfare Programs

Residency (referred as post-graduation in India) can a stressful time for the residents, especially when it comes to much demanding acute care specialties like Acute Medicine, Emergency Medicine and Critical Care. It is a period of enormous personal as well as professional development, when trainees identify themselves with consultants and unknowingly introject many of their qualities and behaviours, making them a part of their own personality. 

As budding physicians residents learn a plenty of new skills, take responsibility for the sick patients and also understand how to communicate with distressed patients and families. They do come across hard situations that they have not dealt with before and if not taken care of at the right time, these issues can have a deeper impact on their working ability and lead to physician impairment and burnout. EM needs a special mention here  because Emergency docs work in the most unexpected and uncertain circumstances. Over years they learn how to converse with all the other services working in different parts of the hospital. They have no other option but to learn and speak the language the other co-specialities understand and then further gauge things as per individual preferences. 

And Emergency Medicine is one such speciality, where your work is almost always cross checked by a "specialist" or one of your colleagues and people judge you based on that without appreciating the kind of circumstances under which you worked. We all know that medicine is not always seen as blacks and whites. Opinions differ many times and there is always a potential for a conflict!

These issues might sound trivial alone but we need look at the bigger picture to really understand how all these minor sounding issues together, can affect the performance and mental health of residents. It is therefore essential to understand the the residents' perspective and look at what problems they are facing on day to day basis and only then we can figure out together on working towards "Resident Wellness" because only healthy (mentally and physically) residents can provide quality care to sick patients.

clubfnh.files.wordpress.com

Here are some key issues with Resident Wellness:

• Sleep Deprivation
• Long working hours
• Difficult Consultants
• Difficult work relationships (with nurses/colleagues) 
• Difficult Patients
• Peer Competition
• Exposure to infections/ patient mortality

Specific Issues with women:

• Discrimination (Patients often assume female physicians as nurses!)
• Lack of female role models
• Multiple Responsibilities (marriage, family, motherhood)

As a speciality, EM is still in the developmental stages in many parts of the world. Some trainees choose it out of interest and others because they did not match anywhere else! Trainees might also feel that they have nobody around to look up to because hospitals often employ is a single consultant for a 15-20 bedded ED.  

If greater attention is paid towards physicians and residents well-being, it can be associated with better patient care. There are some possible ways out through which we can try and fix these problems. 

Residency Programs should have:

• Annual Leave Policy
• Fixed Duty Hours
• Circadian Scheduling policy (Considering personal preferences)
• Wellness Workshops (for nursing as well as medical staff)
• Including wellness in the curriculum
• Teaching personal safety skills, communication and negotiation 
• Record all the didactic sessions (Night workers can watch them at their own ease)
• Department social events (interdepartmental as well as intra-departmental)

For the residency programs, it is frequently not possible to stick to all these measures due to various reasons, and residents also must take some onus to work towards their own wellness by having individual coping mechanisms like:

• Have a written set of goals for every trimester/semester
• Have a mentor
• Always try and think from the other person's perspective
• Have a fixed time for friends/family
• Exercise and eat well 
• Learn to communicate well: This can make or spoil your day!
• Prioritise and learn to say "no" to a few things

Dealing with other specific issues:

• Substance Abuse: Encourage self reporting, Speak to the program director
• Circadian Disruption: Learn the art of working in shifts
• Litigation: Improve documentation, Know the risk management strategies 
• Exposure to diseases: Always and Always use PPE
• Exposure to Mortality: Post death debriefing, Spend time with friends/family and understand that death is part of EM

Key Points:

• Acknowledge the fact that as an emergency health care providers, you are vulnerable.
• As residents, work with the residency program to create a healthy learning environment. 
• Appreciate the opportunities created by the residency programs and make the most out of it.

To keep the body in good health is a duty...otherwise we shall not be able to keep our mind strong and clear - Buddha

Further Reading:

• Schmitz GR, Clark M, Heron S, et al. Strategies for coping with stress in emergency medicine: Early education is vital. Journal of Emergencies, Trauma, and Shock. 2012;5(1):64-69. doi:10.4103/0974-2700.93117.
• Schwartz AJ, Black ER, Goldstein MG, et al. Levels and causes of stress among residents. J Med Educ. 1987; 62:744-753.
• Whitley TW, Gallery ME, Allison ED, et al. Factors associated with stress among emergency medicine residents, Ann Emerg Med. 1989; 18: 1157-1161.
• Houry D, Shockley L, Markovchick V. Wellness issues and the emergency medicine resident. Ann Emerg Med. 2000;35:394–7.

Constant Jet Lag in Emergency Medicine

Emergency Medicine is high risk speciality that brings a lot of stress with it and maximum burn out rates among its providers. A major reason why people quit EM is due to the rotating shifts. And as we turn older, it gets difficult to cope up with this ever changing shift work schedule. Many of us suffer from this under appreciated problem of shift work disorder. Rather than accepting Shift Work Disorder (SWD) as something that always comes along with EM, we should find out ways and learn how to cope up with it. 

What is Shift Work Disorder?

SWD is clinically recognized condition that develops in some individuals who work at night, start work early in the morning (4am-7am), or work according to a rotating shift schedule. SWD consists of a constant or recurrent pattern of sleep interruption that results in difficulty sleeping when you should sleep or excessive sleepiness when you are supposed to stay awake and alert. 

Problems that might occur with Shift workers:

Medical errors 

Disturbed circadian rhythm

Risk of peptic ulcer disease

Cardiovascular disease
Hypertension

Chronic Fatigue, insomnia

High Divorce rate

Substance abuse and Depression

Immunosuppression

Fertility issues

Poor dietary choices

Thyroid issues

Most circadian rhythms have both an endogenous component (regulated by suprachiasmatic nucleus of the hypothalamus) and an exogenous component. The exogenous component is composed of various time clues called zeitgebers. One of the most powerful zeitgebers is the light/dark cycle (e.g. Sun). Other examples of zeitgebers can be food, television, exercise, caffeine, sports. We can synchronise with these zeitgebers and give the right cues to our body to promote wakefulness/sleep. 

For instance , prior to starting a night shift, exercising OR eating typical breakfast foods OR exposure to bright light gives subtle clues to your body that it is time to get up and start the day. Similarly, having a cup of coffee, bright light exposure and exercising after a night shift is a bad idea!!

Few Strategies for setting up night shifts:

1. If you can work it out, then the best way is to do a stretch of nights for 6-8 weeks once in a year. This way you would need to change your sleep cycle only twice a year (not every week!). No meetings/academic sessions after night shifts.

2. Casino Shifts: With casino shifts, one long night shift is cut into two short shifts, from 10pm-4am and from 4am to 10am. With these shifts the "early risers" turn up for the 4am shift and people who prefer to sleep late in the night leave by 4am. Both these groups can then continue their next day normally without affecting their social liv. Some people like and prefer to work like this.

3. Avoid doing >2-3 nights in a row.

Shift Length: Some physicians prefer shorter shifts (6-8hrs) and some like to stick to the 12hr shifts. With shorter shifts, it is found that physicians are more alert and respond better while with the two 12hr shifts, you get more days off per week. 

Here are some things that we can do to cope up with Shift work:

1. Education and Awareness (For shift workers as well as their families)

2. Individual Strategies

Prior to night shift, To promote wakefullness:

• Make sure you get some sleep during the day time (Never start a night shift in sleep deprivation)
• Exercise in the evening 
• Expose yourself to bright light 
• Having more staff overnight is beneficial
• Have dedicated breaks, with coffee and high protein foods

During night shift, To stay alert 

• Keep your naps short (<30 minutes)
• Stay exposed to bright light
• Have a high carbohydrate/protein snack to keep you awake
• Caffeine (only during the first half of shift)

After night shift, To promote sleep:

• Use sunglasses while travelling back home to avoid bright light exposure
• Use ear plugs/eye protectors, black curtains 
• Make sure that your room temperature is comfortable 
• Keep your kids and pets away to avoid disturbances while you are asleep (Noisy environments cause sleep fragmentation)
• Have a dedicated quiet area to sleep
• Avoid fatty/ spicy food before you sleep
• Avoid early morning caffeine 
• Switch off your phone and try using an answering machine

Shift schedule should be made by someone who understands SWD

ACEP endorses the following principles:

• Scheduling isolated night shifts or relatively long sequences of night shifts is recommended. 
• Overly long shifts or inordinately long stretches of shifts on consecutive days should be avoided whenever possible. In most settings, shifts should last twelve hours or less. Schedulers should take into consideration the total number of hours worked by each practitioner and the intervals of time off between shifts. 
• ACEP strongly recommends that practitioners have regularly scheduled periods of at least 24 hours off work. 
• Rotating shifts in a clockwise manner (day to evening to night) is preferred.
• Night shift workers' schedules must be designed carefully to provide for anchor sleep periods, and those workers' daytime responsibilities should be held to an absolute minimum. 
• Groups should consider various incentives to compensate those working predominantly night shifts. 
• Schedules for emergency physicians should take into account factors such as ED volume, patient acuity levels, non-clinical responsibilities, and individual physician's age. 
• A place to sleep before driving home after night shifts should be provided.

3. Pharmacolgy

To promote sleep:

BZDs (addiction, side effects)

Zolpidem is better than BZDs

Melatonin: take few hours prior to sleep, dose: 0.5-5mg

Stimulants to promote wakefullness:

Modafinil (Dopamine reuptake inhibitor, Also activates Glutamate and inhibits GABA)

Caffeine: Too much leads to agitation, tolerance overtime and withdrawal. Avoid taking caffeine during the second half of your shift.
Energy drinks: Caffeine + sugar 

Key Points

• Educate your family and colleagues about Shift Work Disorder
• Learn how to play with the zeitgebers
• Do not overly on medications
• Consider incentives for those who work the unpopular night shifts 

References:

1.Haney Mallemat - Shift Work Disorder: http://www.emedhome.com/cme_infocus.cfm

2.https://www.acep.org/Clinical---Practice-Management/Emergency-Physician-Shift-Work/

3.Boggild H, Knutsson A. Shift work, risk factors and cardiovascular disease. Scand J Work

Environ Health. 1999;25:85-99.

4.http://www.acep.org/Clinical---Practice-Management/Circadian-Rhythms-and-Shift-Work/

5.http://www.gru.edu/mcg/clerkships/em/documents/shiftwork.pdf

6.http://cjem-online.ca/v15/s1/the-impact-of-“casino-shifts”-on-emergency-physician-productivity