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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 16, 2015

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.

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