Control

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.

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11 Responses to Control

  1. Amanda Xi says:

    This is probably one of my greatest fears going into my OSCE this week — good thing our patients are trained to be compliant.

    Either way, I’m sure somehow find a way to integrate the humanistic side into the patient interview… after all, no patient will appreciate us if we’re controlling them.

    Good luck with the end of your semester!

  2. Shara Yurkiewicz says:

    I am also scared about the OSCE, but mainly because I don’t think I’ve had enough experience practicing my physical exam skills on actual patients (obviously). Many times, a patient is too tired or sick for us to get through the entire exam, so we pick the bits and pieces that are relevant. It’s been very piecemeal so far.

    Good luck to you this week.

  3. Jared says:

    Nice introspective analysis. I don’t really know, but imagine that medical students are better than most at constructive self critical critical reflection, but yours seems especially honest to me. I bet you’ll make a fine physician, and one that I’d prefer over many.

  4. “You need to control your patient.”

    That strikes me as a very odd comment. What does “control” even mean with regard to another human being? Maybe thanking your patient did not go over well with this particular preceptor, but I can bet it goes over well with the patients.

    Also, I am majorly impressed that you had the courage to post about an experience that you were not proud of. I know it probably doesn’t mean as much coming from someone who shares 50% of your DNA, but I think you’re doing great :)

  5. Sarah says:

    There is a lot that I would like to say in response to your post, but I’m not sure that it all translates well into words. I’m on the other side of this, an attending who has been out of residency for a couple of years.

    Your teachers will tell you that you should interact with patients this way or that, and they will say it with conviction. They will often be wrong. You need to find your own way to an honest working relationship with patients that you are proud of. The hard part is validating that process for yourself when you are hearing interference from those in positions of authority.

    You will see patients not being listened to by the team, or not receiving appropriate interpretation when English is their second language, and you will struggle to figure out how to say something–how do you obey the hierarchy enough to move onward and upward, but without betraying the doctor you want to become? In those times, your suggestions might be the most important aspect of the patient care plan in the room. I’ve had a student lean down to speak quietly and explain what was happening to a crashing but alert patient while I was getting my team organized for an imminent procedure without speaking to the patient–I should have done that, and I learned from my student. It is a lifelong struggle to be a better doctor and everyone is bringing something valuable to the table.

    One of my biggest issues with the dysfunction of medical school is that you are suddenly judged by incredibly subjective standards from a wide variety of viewpoints–and you are being evaluated on being a superb physician, something you have worked so incredibly hard for and have wanted so much. When I look back, so many things I that were not positively enforced or that received outright negative feedback ended up being extremely valuable in taking better care of patients and connecting with people who might have held me at a distance. Your preceptors can teach you a wide variety of skill sets and tricks of the trade, but ultimately you are on your own to create the best physician you can out of yourself. And your opinion of yourself and of your interactions with others is extremely valuable. You are developing the only consistent assessment of your progress that you will have to go by throughout the years.

    Remember this interaction when you are teaching students (although I do appreciate the Eternal Sunshine reference), and you will be able to congratulate your students on being possibly the only bright spot on a patient’s dark hospitalization, on getting more history from her than anyone else had, on performing service recovery and giving her a better hospital experience to remember so she won’t wait till she’s at death’s door to come in next time. And then maybe describe a few ways to transition smoothly to the physical exam, if it seems like the right thing to teach right then. You’re going to have most of this figured out someday soon and the struggle will feel more distant. Keep valuing your own opinion and keep actively deciding what kind of doctor you want to be. You’ll get there.

  6. Shara Yurkiewicz says:

    Thank you so much, Sarah. I really appreciate that you took the time to write that out. Your comment alone is more informative than my post.

    It helps a great deal to have wiser people give you this sort of perspective. Medical school becomes a sea of subjectivity, and it’s hard to know which feedback to keep and which to toss. To thine own self be true? With conditions?

  7. Tom says:

    From the patient side of things: when I was in the hospital a couple of times at the start of last month after a bicycle accident, some medical students who recognized me as a human being and showed actual concern for me as an individual were one of the first bright spots in what had been to that point a very impersonal medical machine. So I hope you are able to keep your ability to care about patients, make them feel comfortable, and reduce their frustration with the medical apparatus while adding more ability to also get through the things you need to to give good care. I am sure that will come with practice, the ability to interact well with patients either doesn’t, or too many doctors never bother to learn, so you are already partially ahead of the game in my book.

  8. LA Morrison says:

    I can relate to the issues brought up in your post. As a soon-to-be intern, I am considering how “humanistic” I can be with my patients and still manage their care, review their records, and provide efficient care. This is especially challenging with my favorite population– geriatric patients.

    Like you, I have witnessed attendings disregard their patients’ thoughts and concerns, as well as others who truly value the patient perspective. I have learned the art of the H&P from empathic physicians, and have been able to extract crucial details after allowing a patient to talk, feel comfortable, and express their thoughts. (Example 1 – learning of a woman’s domestic violence situation after admission to the hospital for MI; Example 2- watching a patient’s BP decrease simply by talking to him and reassuring him).

    Don’t discount the power of benevolence!

  9. Shara Yurkiewicz says:

    It is indeed disconcerting when those with years’ more experience than you don’t do everything right. It’s not always clear in the moment, either; then, hours later, you begin to reflect, question, doubt…

    I also wonder how I will ever manage to spend sufficient time with patients when I actually have a real workload and am responsible for their care.

  10. I have received similar comments on past OSCEs. They stung me, but I later came to realize that they have some degree of salience. A surgeon told me that it is difficult to offer anything but pith when you are responsible for an emergent decision — in fact, anything else may provoke more anxiety in the patient. (That may sound obvious to some readers, but I have found in my own attempts to do it that an effort to elicit quick answers can preclude the interviewer from offering basic pleasantries.) Another, a psychiatrist, was more convincing when she explained to me that reflexive validation of the patient’s concerns can undermine rapport. A patient whose experience of illness derives from an addiction we have never experienced ourselves, or from a family life or economic circumstances nothing like our own, may find our insistence on thanking them for sharing to be inappropriate or insincere. Her observation struck me as cool at the time, but I get it more now: We are there to offer presence, not empathy. Empathy fuels better writing, and makes more sensitive clinicians, but the patient needs a partner and a steward in the immediate term. As the screenwriter David Milch put it, the vocation of the doctor is not curative, but pastoral.

    That said, I have witnessed innumerable patient interviews like those Sarah, the earlier commenter, describes–and I am only halfway through MS3. They are damning to patient dignity, and under a broken hospital administrative structure, decency is about all we have to let our patients know we are on their side. So I’ve come to believe that treating the system may be the only way we have left to protect the value of the individual patient encounter. Medical professionalism cannot exist, let alone thrive, under a financial structure in which physicians get paid more for spending less time with the patient. It’s hard for me to indulge health care institutions’ constant preaching about our responsibility as clinicians to restore a culture of “medical professionalism” when we as professionals are discouraged from speaking out against the incentives in our profession to maintain a warped model of distributive ethics. If we are put off by curt treatment–emotional abuse, really–of our patients, we have a responsibility as clinicians to defend our case for a just health care insurance system to the rest of the country. I think you are already doing as much, but I know that my own classmates and I are too often tempted to think toward the next OSCE rather than to the outside world.

    If your instinct to show a patient you are willing to spend extra time with him or her comes at the expense of a better clinical grade, you are not in the wrong. You are sharp to smart at this kind of feedback, and I hope your friends who have had similar experiences developing a network of real-world actors who oppose to a health care system that prevents you from applying your time and your smartness toward the greater good.

  11. Joanne says:

    I love your story telling. I know I have read other things by you in the past, but never commented.

    One of my favorite people in the world is a kind, compassionate doctor to be (with a PhD to boot). Wish he could have stayed an worked as a TA for me forever, but who am I to prevent a great future physician from his appointed goal?

    I look forward to saying “Hi” at #scio12!