If Harvard had a habit of failing its students, I would have failed my observed patient interview last week.
Take a patient history and do a physical exam. It was the same exercise we had been doing for the last several months. This time, a preceptor would be observing me. Or evaluating me. Or helping me. I wasn’t sure; everyone’s style differed.
Unsurprisingly, my assigned patient had been discharged, so I began the manhunt for a backup. I eyed the room next door, and my preceptor eyed me. I stopped outside to sanitize my hands. A tired-looking man walked over to me.
“My mother’s pretty pissed right now. She was supposed to be discharged today, but they’re delaying it by a few hours. You sure you want to go in there?”
I was absolutely sure I did not. I was about to thank him for the warning and make a beeline for a more agreeable patient to prod verbally and physically, when my preceptor said, “Oh, that should be fine.”
This turned out to be a big fat lie.
Forty five minutes later, we emerged from the room with a complete history but no physical exam. My preceptor put his arm around me and said immediately, “You need to control your patient.”
After throwing myself a private pity party, I complained to my friend that evening. “What do you mean, you just didn’t do the physical exam?” she said. It was incomprehensible, what I managed to do. I managed to run out of time because a) I didn’t clarify with my preceptor beforehand how much time I would be allotted (it was half of what I expected and what my classmates had received), and b) I couldn’t get the patient to stop talking and start doing. I felt like the world’s worst medical student.
I watched as my preceptor attempted to fill out my evaluation form with me. He couldn’t even fudge my performance on the exam, since it was non-existent. Blank, blank, blank, blank. Patient rapport: excellent. Blank, blank.
It’s not a new problem, the struggle I have with balancing politeness and aggressiveness, trust and control. To put it politely, I was frustrated.
I was frustrated that the habits that make me a good listener in most situations made me a lousy diagnostician with a difficult patient. I was taught not to interrupt (and not just with patients). I usually wait at least a beat after the speaker finishes before I start talking. But for an angry patient, that beat is enough time for her to dredge up another complaint and run with it. Then the game begins anew, and I have to figure out where to intercept her next to get more of my questions answered. It’s an exhausting game of mental football, and I’m concerned about making her bad mood worse–for selfish and unselfish reasons.
I vividly remember reading the studies that say physicians wait an average of about 20 seconds before interrupting their patients at the start of the interview. I mentioned that to my preceptor. “It takes a patient about two minutes to give you what you need to know,” he said. Touche. I had overshot that several times.
I was frustrated on a grander scale, thinking about my involvement with health media and my blog, which are distinctly more humanist than scientific. Had I become too soft, falling for bedside manner at the expense of competence? There is less coverage in the mainstream media of a major part of health care: correctly diagnosing a set of incredibly non-specific and non-consistent symptoms. There is little appreciation of the untangling of relevant from irrelevant, particularly when the patient’s narrative may lead you astray and you must rein in the meanderings.
Mainly, I was frustrated that I somehow managed to become too polite to be an effective doctor-in-training.
One of my classmates received similar criticism during a psychiatric interview. “You took what the patient said at face value and didn’t challenge him enough,” the instructor told him. That same instructor grilled the patient later in the interview, who immediately became defensive and closed off. An improvement? I thought, doubtfully. Is he lying less to you now?
I am frustrated because people who presumably know more than I do are telling me to do things that go against my basic social mores.
“You thanked your patient too much,” my preceptor told me. “You also asked her too many times if she was comfortable. That projects anxiousness on your part.” But she was angry at the entire medical world and I wanted her to trust me, I silently countered. Plus, I cared if she was comfortable. Plus, she called me adorable. Plus, I fundamentally disagree with your assessment.
“I want to Eternal Sunshine this entire experience,” I said later to my friend. But, obviously, Joel and Clementine are doomed to make the same mistakes if they erase wisdom gained from experience. Embarrassing and painful as it is, I have to mull this one over.
I’m certainly not in denial that I made an uncountable number of mistakes. I will change. I will improve. I will pull off the physical exam. I will “control my patient.” But–I will also thank my patient until I’m blue in the face.