If you visit my clinic, I follow a structured process during the the encounter. It’s fairly traditional but has some hidden twists that I think are worth thinking about.
Introduction (provider directed). During the first few minutes I try to connect and find some type of common ground with the child and parents. Basic, human stuff.
Landscape of the encounter (provider directed). I always outline the course of the visit. Kids want to know what’s going to happen – it puts them at ease. Parents like hearing that their problem is going to be handled systematically. I discuss the sequence of history, exam and discussion at the whiteboard. I remind the parents that I’ll be typing at my EMR during my history and that I will likely have periods where my eye contact is with the screen.
Why are you here (patient directed). This is a subjective element of the history where the family leads off. They share why they’re here. For families accustomed to only 5 minutes with a doctor there can be a tendency to ‘dump’ their history. A pressured, rapid-fire summary of their story. If I hear this happening or once I feel they’ve shared the core reason for the visit I’ll ask permission to lead into some specific questions about their complaint. For patients unclear as to what to say and how much to say, this suggestion is typically taken with relief. The burden of properly packaging a story can be significant for a nervous mom.
History (provider directed). I take a fairly focused approach to this part of the visit. This is where I learn the where, when, why, how of the complaint. For a child with abdominal pain I may ask as many as 50 questions. With each answer I create hypotheses that I test with follow-up questions. This gives me the critical information I need to help understand their problem. In my line of work, this is where the money’s at. I finish by asking ‘That was alot of questions…Is there anything that I failed to ask you about that I need to know?”
The patient’s opinion (patient directed). After I feel like I’ve collected the required objective information I turn the mike over to the family by asking an open-ended question that help me understand their thoughts about the problem. Depending on the case, I might ask what they understand about what’s happening. I ask their opinion of the problem – their hypothesis. Sometimes it’s helpful to find out what worries the parents most. These questions offer powerful information regarding the patient’s perspective. It can reveal what’s been called ‘the hidden agenda.’ This dialog usually happens naturally as I’m washing my hands and starting the physical.
Physical Exam (provider directed). This the touchy feely part that speaks for itself.
Assessment and plan (mutually directed). I start at the whiteboard with a concise bullet list of key symptoms followed by a discussion of potential issues that could be behind the child’s problem. I recommend a course of action and we discuss. A lot of what I do and when I do it is subject to negotiation with a family.
As you can see, I think of two ‘modes’ of direction during the course of the visit: 1) my collection of objective information and 2) the patient’s subjective perspective on their issue. Both are important and offer balanced control. But when I’m collecting my information I do it in a methodical, focused way. When the family is opening up to something it’s their time. I like to keep the two compartmentalized. It’s my process.
It’s important that we teach the next generation to think critically about their time with patients. What I see are young physicians who fail to conduct interviews but rather follow the flow of a patient encounter in a disorganized, meandering way. “I couldn’t get a word in,” I hear. “The mother wouldn’t stop talking.” They seem hesitant to assert themselves. This leads to an inefficient use of time for both the patient and the provider.
While we fantasize that time is an unlimited resource when it comes to a patient’s needs, reality dictates that time is a resource that must be allocated.
A medical interview needs leadership. It needs a conductor.