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Empowering Healthcare patient-doctor relationship

Making your doctor more attentive

St Stephen's Basilica, Budapest, Hungary
St Stephen’s Basilica, Budapest, Hungary

My golden rule of medicine is this: Treat every patient with the same care I would want for my best friends and family. I order the same tests, refer to the same consultants and offer the same treatment options.

When I teach medical students about hand washing to prevent the spread of infection between patients, I encourage them to consider it as an important ritual between closing an encounter with one patient and being fully present for another.

When health care providers are rushing from patient to patient, not only are they less likely to clean their hands sufficiently with soap and water or alcohol-based hand sanitizers but they are more likely to be inattentive and make mistakes.

When we are not observant, thoughtful and listening, we miss out on valuable clues, jump to the wrong diagnosis and fail to really help that patient. An experienced clinician develops intuition, and a wise one attends to it.

If our diagnosis doesn’t quite match all the symptoms and physical findings or if we feel that we are missing out on some crucial information, we leave the examination room feeling uneasy. If we ignore that feeling and move on to the next patient, we may be preoccupied and not fully present again. This can have a snowball effect to the detriment of every patient seen that day.

So I teach mindfulness meditation to patients, medical students, residents and colleagues. With each patient’s visit, that patient must be the centre of our attention. We must listen carefully, ask the right questions and perform an appropriate and focussed physical examination. We must consider a broad differential diagnosis. What conditions may explain these symptoms and physical findings? We don’t settle for the most common diagnosis especially if it doesn’t quite fit. We consider less common and more serious possibilities.

We all know that feeling when we have a conversation with someone who isn’t fully present. They may ask, “How are you doing?” but don’t really listen to your answer. They don’t have to be texting to show that they’re not all there.

Healthcare providers can easily fall into a mindless routine, rushing from patient to patient, asking a rapid-fire list of oft rehearsed clichéd medical questions, jumping to the most common diagnosis, not really seeing the person in front of them, and moving on to the next in line.

If you ever get the feeling that the doctor is rushing and may have jumped to the wrong diagnosis, there are ways of triggering a pause and reflection.

I recommend to friends, family members and any of my patients who might be treated at another clinic or hospital – perhaps in another town – three key questions.

1. What else could it be? This forces the doctor to step back and to reconsider the diagnosis. Could it be something other than the obvious that doesn’t quite fit? Do I need more information? Should I ask more questions?

2. What is the worst thing it could be? This triggers the doctor to consider worst case scenarios. One of my patients is alive today because I considered one of the rare but serious possibilities for her worsening sore throat and fever. A day earlier, the nurse attending her during the colonoscopy told her she probably had a cold. That night, the emergency physician prescribed antibiotics for strep throat. I recognized the subcutaneous emphysema – air released from her perforated bowel that had tracked under her skin up to her throat. I sent her to another surgeon who saved her life by removing the injured portion of her bowel and treated the resulting infection with IV antibiotics.

3. What would you recommend if I was your mother (or father)? This of course asks the doctor to consider the golden rule – a gentle reminder that you are someone else’s loved one and deserve that same special attention and consideration.

Dr. Davidicus Wong is a family physician and a Clinical Assistant Professor in the Faculty of Medicine at UBC.

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Burnaby Division of Family Practice Empowering Healthcare patient-doctor relationship

Getting the most from your doctor’s visit

Have you ever left your doctor’s office having forgotten to ask an important question . . . or arrived home not totally clear about everything you had discussed during your visit?

This happens all too frequently and it doesn’t mean that you have dementia or you weren’t paying attention. Yet what we missed may be bad for your health.

The information you didn’t share with your doctor may have been as important as anything else you had discussed at your visit. If you are not clear on your plan of management, you’re unlikely to get the best results.

Old-time doctors used to call patients “noncompliant” when they failed to start an exercise program, eat a healthier diet or take their medications as prescribed. Enlightened doctors today recognize that when a patient doesn’t follow through with the plan, it means one of three things: (1) we weren’t prepared for obstacles to success, (2) we didn’t effectively communicate the management plan, or (3) the plan was the doctor’s and not the patient’s.

Effective communication in the form of dialogue is crucial to every relationship. In your personal relationships at home, it’s the key to happiness. In the professional relationship with your doctor, it’s crucial for health.

That communication begins with your call to book an appointment. The medical office assistant will ask for the reason of your visit. If there is more than one, give them all when you’re booking.

The medical office assistant is part of your health care team and can be trusted with your confidentiality. She or he helps the office run more smoothly so that all patients can be well served.

Being human, we may pick up an infection or discover new problems before we see the doctor. If you do, advise the medical office assistant when you arrive. This will ensure that the doctor is best prepared for your visit.

Some problems require specific instruments, gowns or other preparations. Work-related or MVA-related injuries may require important detailed information and specific forms.

If you are suffering from depression, anxiety or a stressful situation, additional time may be required for counselling.

The first few minutes of your visit is the best time to clarify everything you need to address. Your doctor may have some additional items to discuss with you, including the results of recent investigations or screening tests that are due. It’s important to agree on your shared agenda at the beginning of your visit just as you would at the beginning of a meeting at work.

Each problem you present requires the doctor to take a thorough history including the asking of crucial questions and to perform a physical examination to rule in or out important conditions. When the working diagnosis is clear, the doctor may propose a management plan and alternative choices for treatment. You need the opportunity to ask questions and to get all the information you need to make informed choices.

Obviously, if your doctor has to work through this process sequentially as you pull a series of problems from your pocket one at a time, a 10 or 15 minute appointment can turn into an hour, sabotaging the medical office assistant’s mission of keeping the office running smoothly to serve all patients well.

So the first thing you can do to get the most of your doctor’s visit is to come prepared. Write your list of problems and bring it with any other information that may assist your doctor. Share it with the medical office assistant – your ally in the office – and your family physician.

In upcoming columns, I’ll address the management plan and the crucial information you need to know about any medication, investigation or treatment in order to make an informed choice and remain in the driver’s seat in your own health care.

On Monday, February 17th, I will be speaking at the Metrotown branch of the Burnaby Public Library on “The Patient-Doctor Relationship: making the most of each visit with your family doctor.” For more information, please phone the Metrotown branch at (604) 436-5400 or register online at http://www.bpl.bc.ca/events.Image

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patient-doctor relationship

Humanizing the Medical Interview

The traditional way medical students were once taught to take a medical history often turned into a barrage of close-ended questions that could actually limit doctors’ understanding of patients’ experience of illness.

I’m happy to report that medical school has evolved. Students are learning early to listen better, to ask more open-ended questions and to invite patients to share more information.

We know that patients put a lot of thought into how they are going to explain their problems to their physicians. They might be rehearsing what they’re going to say on the way to the clinic or hospital and again just before they meet with their doctors.

When I teach medical students and residents, I remind them that the old adage that the diagnosis is in the history really means that often the patient will tell us the diagnosis but we have to listen.

After making the patient feel at ease, I encourage my students to let a patient talk about their symptoms without interruption. Studies have shown that most doctors interrupt patients within two minutes, and when this happens, they lose their train of thought and crucial information is missed.

By taking time to listen first, we gain more than launching in the typical medical inquisition. Students are now taught to ask more open-ended questions that invite more elaboration from the patient as opposed to the yes or no responses to close-ended questions.

Medical students throughout Canada are taught to attend to more than the physical symptoms of illness. They learn the acronym, FIFE. This reminds them to ask patients about their feelings (fears and other feelings related to the experience of their illness), ideas (the patients’ own ideas about their condition), function (how the illness affects their daily lives) and expectations (what they expect from the doctor and from their condition).

Though old habits are difficult to change, I’m optimistic that doctors will continue to improve the way they communicate and relate to their patients. You could help.

Do you have any comments or suggestions on how patients and doctors communicate? Please share your ideas here.

Categories
patient-doctor relationship

The Medical Inquisition: The Downsides of Traditional History-Taking

Medical students are taught to take a careful history because in most cases, therein lies the patient’s diagnosis.

When I was in medical school, we were taught how to “take a history.” This included: the history of the present illness (the presenting problem, when it began and the details of the patient’s symptoms), the review of systems (an inquiry into all the major organ systems), the patient’s past medical history (including allergies, operations and significant illnesses and hospitalizations) and family medical history.

As students, we tended to focus on getting specific details from the patient, and this often resulted in what must seem like a barrage of questions. These are intended to rule in or rule out particular medical conditions.

Particular conditions often follow a predictable pattern of presentation. For example, the pain of gallstones is often described as crampy right upper abdominal pain radiating into the back following a heavy or fatty meal.

The classical symptoms of very high blood sugars from uncontrolled diabetes are excessive thirst, hunger, urination and weight loss.

Sometimes, in the search for the diagnosis, we could get caught up in the questions and try to fit the patient into a recognizable pattern.

Physicians trained in this way, may fall into a pattern of asking many close-ended questions. The problem with this is that we limit the information we get in response, and some of the missed information may be crucial to the correct diagnosis.

Next: The good news about how medical school has improved how doctors are trained to interview.

Categories
patient-doctor relationship

What You Should Know About History-taking

The history begins with your description of your symptoms. When they began and how they have changed over time. Once you’ve initially presented these symptoms, your doctor will ask you more detailed questions that can flesh out crucial details that may distinguish a number of different causes.

What makes your symptoms better? What makes them worse? If you are experiencing pain, does it start in one place and radiate to another area? What type of pain is it (squeezing, sharp, crampy, burning or achy)?

This question can be challenging for some to answer. To many, pain is just pain. If you haven’t experienced a variety of different types of pain, it might be hard to distinguish the different types. It’s not unlike being an inexperienced wine taster and not being able to distinguish such subtleties.

Language and culture also influence your description.

Pain due to gastroenteritis, periods and labour are described as crampy. Pain from the passage of kidney and gall stones is typically colicky. Angina or chest pain from narrowed coronary arteries is typically – but not always – squeezing.

With angina, discomfort may radiate into the throat and neck or to either arm. Here typical exacerbating and alleviating factors are very important. Angina typically comes on with anything that increases the work of the heart, such as exertion (exercise) and anxiety – in short, physical or emotional stress.

Are there other symptoms associated with your primary symptom?

Nausea or queasiness is commonly associated with angina. In some cases, it may be the only symptom. Patients may experience nausea with exertion and acute stress without the typical chest pain.

That’s why – to you and your doctors – history is so important.

Next: the doctor’s inquisition – why we ask questions the way we do.

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patient-doctor relationship Uncategorized

What You Should Know: The Structure of Every Medical Visit

By tradition, every medical visit has a common structure.

I’m sure you recognize the basic design. You present your problem. Your doctor asks you questions about it then does a focused physical examination, makes a diagnosis and comes up with a plan for further tests or treatment.

This four-part structure is summarized in your medical records. In your family doctor’s charts, a common format for visit entries uses the acronym SOAP that stands for subjective, objective, assessment and plan.

This form of record keeping helps anyone reading the chart – for example a physician filling in for your doctor or any other health care provider you’ve authorized to give you care – to understand the thinking processes of your physician – how the diagnosis was determined and what the treatment plan is.

Familiarity with this traditional process can help you understand the pace and flow of each medical visit and as we’ll see in upcoming columns, improve communication and satisfaction in your interactions with your physicians.

When you present to your doctor a medical problem, such as abdominal pain. You might have a clear idea of what the cause might be. Though your doctor will keep your diagnosis high on the list of possible diagnoses (known as the differential diagnosis), the history, examination findings and the results of investigations will narrow the list of possible diagnoses to the most likely – and hopefully the correct – diagnosis.

Next: How your doctor “takes a history.”

Categories
patient-doctor relationship Relationships

What’s Going on in Your Doctor’s Head?

You may have heard your computer revving high, consuming RAM while it is working on some tasks in the background while you answer your e-mails or surf the net. A similar process occupies a large part of your doctor’s brain while the two of you are conversing.

That’s why at some point – sometimes it may seem too early in your meeting – your doctor will start interrupting you with focused questioning in our typical clinical style.

These are the diagnostic questions we learned well in medical school and refined through countless patient encounters. At this moment, the doctor is consumed by the hunt to get to the diagnosis as quickly as possible.

We can be thrown off the scent by the interruption of multiple unrelated problems you might bring up. Our hard drives may freeze up like your computer when you open too many windows.

To prevent this brain freeze or to keep your doctor on task – your task, it may be helpful for both patient and doctor to be upfront in setting the agenda and approach to each visit up front, right at the beginning of the appointment. Let’s have more transparency.

Next: understanding the structure of every medical visit.

Do you have some suggestions for how patients and doctors communicate? Please leave your comments here.

Dr. Davidicus Wong is a family physician. His Healthwise column appears regularly in the Burnaby Now, Vancouver Courier, Coquitlam Now and Royal City Record. You can find his Positive Potential Medicine podcasts at wgrnradio.com.

Categories
patient-doctor relationship

Meeting with Your Doctor: Two Voices, Two Agendas

In recent posts, I wrote of the importance of a shared agenda when you meet with your doctor, and the importance of bringing forth all the items on your agenda – your list – when you book the appointment and clarifying this with your doctors’ staff in the examination room before you see the doctor.

Once you meet with your doctor, how do you negotiate the agenda?

In every human encounter – between parent and child, boyfriend and girlfriend, best buddies, and strangers, there may be a shared and differing priorities.

For your medical visits, however, your wellbeing is the primary concern of both parties. Your doctor may have some other peripheral priorities –his duty to protect and help others, another sicker patient who requires urgent care, the pressure to stay on time and please many people.

It is unlikely that your doctor’s more pressing priorities are a golf date or the hockey score. Most doctors put their patients needs ahead of their own and often ahead of their own families and partners.

In fact, I have often heard colleagues complain that they were so busy in the clinic or attending to hospital patients that they had “no time to pee” or stop for lunch or dinner.

Ironically, the most common conflict in patient-doctor encounters is their different approaches to the patient’s health concerns. In every conversation, there are two voices. At your visit with the doctor, there is your voice – the voice of the patient: a human being who has not only one or more medical concerns but also your own ideas, feelings, fears and expectations about those problems, how they affect the rest of your life and how they should be managed.

The other voice of course is that of the physician. We tend to be focused on problem solving. While you are talking, through the doctor’s head runs a background program that is working through that diagnostic process – looking for patterns in the presentation of your symptoms and working from many possible diagnoses (the differential diagnosis) to the right diagnosis.

Next: What goes on in your doctor’s head?

Any suggestions for improving patient-doctor communication? Please share your comments.

Categories
patient-doctor relationship Relationships

Meeting Your Needs With Your Doctor

Doctors and patients may have quite different priorities when they meet together.

Recognizing this, what can we do as patients and doctors to come to a common understanding and have our needs and expectations met at each visit?

The worst meetings at work are those where the attendees do not share a common purpose or understanding and when they do not begin with a shared agenda. If we take a few moments even before the meeting starts to plan that agenda, we will make the most respectful use of everyone’s time.

What can you do as a patient?

When you book your appointment, tell the office staff everything on your list. Medical office assistants (MOAs) are part of your health care team and they respect your confidentiality.

By informing them of all your concerns, they can book an appropriate appointment time for you and ensure that the doctor has everything that is needed to look after each of them. For example, if you are seeing the doctor for a work-related injury, you may need to provide additional work details or complete some forms before the visit. If you are coming for test results, the MOA will ensure that the reports are in your chart before the doctor meets you. If you need immunizations, the vaccines and any other necessary medical supplies will be in the room when the doctor sees you. This will help your visit run more smoothly with your doctor less distracted by interruptions.

For the same reason, if you have any addition to your list on the day of your visit, let the staff know as soon as possible.

Coming up: How doctors and patients can agree on the agenda.

Categories
patient-doctor relationship Relationships

Meeting with Your Doctor – Agree on Your Agenda

When you visit a doctor in a clinic or in the hospital, it’s not a social call.

It’s not unlike a meeting with each party bringing an agenda of items to discuss as well as individual expectations. The problems begin when the agendas don’t match; the doctor and the patient have different priorities and different expectations for the visit.

Now you’d think that your reason for seeing the doctor should be obvious and straightforward. When you bring a single simple problem – a sore throat, fresh laceration or sports injury, it’s easier for both you and the doctor to stay on the same page.

But your life and your health are more complicated than that; most patients bring in two or more medical concerns. Some may bring a list of six or more, and to make the visit even more unwieldy keep that list in their heads, bringing out one problem after another rather than sharing the entire list up front. It’s like getting into the express line at the grocery checkout then – like a magician – pulling out another dozen items from your pockets and sleeves.

Your doctor may also have an agenda that differs from yours. If you have a chronic condition such as diabetes, a conscientious doctor will want to review your most recent lab results, explain their significance and talk about how you can improve your health.

From the doctor’s point of view, all of this is in your best interests, but if the doctor fails to engage you in the discussion and you aren’t motivated to address these concerns, you won’t be sharing the doctor’s agenda.

Next: How doctors and patients can work better together.

Do you have some suggestions for how patients and doctors relate? Send your comments.