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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 30, 2015

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. 


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! 

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!

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). 


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.

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