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.

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