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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, November 23, 2015

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

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