Introduction to Clinical Medicine: Starting Medical Students to "Walk the Walk"
A physician taking a medical history is a dynamic process and is not simply the physician, as a stenographer, listing data in a chart but should be perhaps the beginning of a therapeutic relationship between the physician and the patient. But for it to be truly therapeutic it also has to be a humanistic relationship in which the patient is a subject and not the object of some medical application.
In the first year "Introduction to Clinical Medicine" at the medical school where I teach, I start out at the very first day of what will turn out to be the career long path of becoming and then being a physician emphasizing this principle. Students on this first day are very uncertain about their role, their responsibilities as a medical student and they are apprehensive interacting with a sick stranger. Issues come up and as facilitator of a group of 6 students we encourage them to "let their hair down" and be open in expressing their concerns to me and the group. Often the issues deal with emotions both on the part of the patient but also frequently on the part of the student. Identification with the situation of the patient, though a valid mechanism for being able to express to the patient true empathy, nevertheless can lead to worry, depression and anxiety on the part of the student if the identification is related to similar ages or similar personal or family diseases.
This identification has disrupted some interviews to the extent that the student can no longer continue talking with the patient because of emotional upset.
What we present the students on the first day, before the first patient interview is an important to facilitate their further functioning. There is much to talk about especially from those facilitators who have had years of experience with all sorts of patients and illnesses. In my opinion, it takes more to help these students through this experience than from an academic professor of communication. You have to have "walked the walk".
To give you an idea of situations which students do face in their first days with a sick stranger, I put together for them a quiz which I usually present, not to grade but as a takeoff for further discussion. Pretend that you are the student and decide which response would be most appropriate and beneficent for the patient. I'll give you my answers later in the Comment section of this thread. In the meantime, I would be interested to know how you would answer the questions if you were a brand new first year medical student who never performed a medical interview on a sick stranger.
By the way, I am off tomorrow to do exactly what I have been writing about on this thread with two groups of first year, first day medical students tomorrow. ..Maurice.
Introduction to the Interview by Maurice Bernstein, M.D.
1. You enter the hospital room of a 44 year old white male who has crumpled Kleenex scattered over the floor and who is coughing. What is the first thing you would say to him? A. “Why are you coughing?” B. “Why did you come to the hospital?” C. “Who are you?” D. “Are you in any pain?” E. If none of the above, what would you say?
2. You enter the hospital room of an elderly white man and there is a bad odor in the room. What should you do first? A. Ignore the odor completely? B. Immediately say to the patient “What is that bad smell?” C. Leave the room at once and call the nurse. D. Without disturbing the patient, during the interview attempt to identify and find the source of the odor. E. Go to the window and open it.
3. Your instructor has assigned you to a 31 year old white female. Moments after the instructor leaves and you are alone with the patient, she yells at you “Get out! Get out of here!” What is the first thing you should do? A.Turn and leave the room immediately without saying a word. B. Sit down on her bed. C. Say to her “I ama first year medical student. Why did you say that?” D. Attempt to hold her hand. E. Say to her “Don’t say that. I was told to interview you.”
4. You enter the hospital room of a 55 year old black female who is moaning in apparent pain and after you introduce yourself what are the next words that you speak? A. “Do you hurt?” B. “When did you come to the hospital?” C. “Are you married?” D. “What is the matter with you?” E. You speak no words but immediately leave the room and call a nurse.
5. You enter the hospital room of a young woman about your age who was assigned to you by your instructor. You observe that she is weeping. What would you do next? A. Leave the room and tell your instructor that you are only a first year medical student and that you don’t know enough to help her. B. Leave the room at once without discussing what you observed with the instructor. C. Identify yourself and then hand the patient a Kleenex from the box on her bed table. D. First ask “What brought you here to the hospital?” E. Leave the room at once and call a nurse.
posted by Maurice Bernstein, M.D. @ 2:03:00 PM
10 comments
10 Comments:
dear Dr Maurice Bernstein
the five interview is very good ,I am a teacher ,now give the answer to the five quesitons ,I am not sure if it is right,
the answer for 1to 5 are D D D D and C ,
could you give me the answer and why .thank you
Anonymous, I would rather wait publishing the appropriate answers so as not to end this challenge for my visitors to come. If you write me e-mail, I can send you back the answers and explanations. My e-mail address is: DoktorMo@aol.com
..Maurice.
By the way, Anonymous, what is the reasons you would give to D D D D C? If we all knew your reasons, that could set off a discussion about their merits and that would be just appropriate for a "discussion blog". ..Maurice.
I can see more than one answer depending upon the context, but I'll give it a try.
1. I might (put my hand on his shoulder)initially say -- "That doesn't sound good at all. Let's see what we can do to help you." Then introduce myself, learn his name, then perhaps say something like "What's going with that cough? Tell me about it." Whether I'd touch him would really depend upon the context.
2. Probably D. The patient might ID the cause of the odor himself if I could get him to feel comfortable and safe. If he doesn't, then I would bring it up.
3. This is a tough one. I'd have to judge how violent the "Get out!" was. If it wasn't violent, I might say: "Okay. I'll leave if you want. But I'd rather stay and see if I can help you." Depending upon the answer or response, I'd either leave for help, respecting the patient's wishes or continue the discussion.
4. Although it seems obvious she's in pain, it might be best to ask "Are you in pain? Where does it hurt?"
5. Actually, I might hand her a Kleenex first, then wait a moment before introducing myself. Sometimes on action can speak louder than any words.
It's a good quiz. It opens up the communication issue to a healthy discussion.
A hint: Think how you would feel if you were a patient in a hospital bed, not feeling well, has on a hospital gown, apprehensive about what will be found and what is the outcome of the hospitalization and then.. ..a person you don't recognize walks into your room and comes over to your bed. What are the first words, the first words, that should come out of that person's mouth? This requirement is something we have to teach our students. Unfortunately, and as been noted on other threads here, there will be some people whom the patient doesn't recognize will come over to the patient's bed and NOT say those important first words. ..Maurice.
I'm not sure what you're asking, doctor. These words are before an introduction, before anything else?
How about: "Good morning." or "Hello." Or, "Hello, I'm Dr. SoandSo, or "How are you feeling?"
Are you implying there's one answer to this question that fits all patients and all contexts? Although I've never been a doctor in this situation, I have been a patient -- I'm not sure, even as a patient, what those words should be. It might depend upon how much pain I was in, or whether I was frustrated, etc. And, regardless of the words, it would depend upon the sincerity and caring behind whatever was said. The words themselves don't convey meaning. It's as much about tone and attitude.
But I would appreciate an introduction, after a hello, and then almost anything that conveyed caring and concern.
Am I getting warm?
MER, you are not only "warm", you are HOT! Introduction, introduction.. it is essential that the healthcare provider or janitor or student or whomever the patient doesn't recognize who comes up to the patient's bed should introduce themselves as their first words. I'm sure you wouldn't want some stranger to start asking you questions, even "how are you?" or fiddle around in the room without knowing who was that person. "I am Maurice Bernstein, a first year medical student and as part of my training to become a doctor, I was assigned by my instructor to talk to you about why you are here, would that be OK with you?" ..Maurice.
Over the years, I've learned that sometimes what seems to be the most obvious needs to be taught. In this case, I see a real perspective and communication gap between patients and health care. What you're doing in teaching is wonderful. Too often teachers assume students know the obvious and don't address it.
In taking this "quiz," my assumption was that an introduction as you describe it was automatic. I assumed that it was understood before we even consider what to say next, and I think most patients assume it too, even if they don't complain when it doesn't happen.
You're teaching the kind of communication skills that we too often just assume are going to happen. They too often don't happen.
MER, unfortunately, in the heat of the day's activities and responsibilities for those entering the patient's room, introduction is not the first thing on their minds. Students, too, unless educated about it, might also naturally have concerns about their performance (what to ask and what to make of what they hear) and ignore that introduction... obviously they don't since before they ever see a patient they are educated about this.
In fact, we look at the introduction and verbal consent by the patient for the interview and examination a critical part of the entire process. It is at the time of the introduction that the student educates the patient about the student's role and the student's required goals in the process and also the role the patient plays in meeting those goals. It is critical that the patient understands that he/she will be working together with the student to meet these goals.
With this kind of introduction not just identifying the student but also introduction into the process, the ensuing history and physical can become a joint-venture. And this is an important point since without this understanding by the patient further interviewing or examination can become more difficult. For example, the student has a limited allotted time to carry out the history and physical. If the patient, during the history taking, goes off on a tangent of talk which is not pertinent to his or her illness, at some point the student needs to redirect the conversation. How easy or difficult it is to politely redirect will be also dependent on the patient's education of the goals of the interview. The same applies to the patient's cooperation with the physical exam. A patient who doesn't understand the reason why the student is attempting to perform parts of a physical that the patient has never experienced even from his or her attending physician can lead to patient resistance to the exam or poor cooperation.
This introduction, after the student explains what needs to be done should also be a time for the patient to relate to the student the patient's own concerns so that both student and patient are on the same track.
It is unfortunate if other healthcare providers don't have the time or interest to carry out their own introduction for the patient. If they did, I am sure there would be less unhappy patients related to the actions and behavior of the providers. ..Maurice.
1.D It sounds like as if you are more concerned. Maybe I'd also say "Would it help if I got you some water?"
2.D Seems like the best way try to embarrass the patient as little as possible and still help him, although he's probably emabarrassed already if he's the source of the smell. But perhaps the smell isn't coming from him?
3.C.
4.D. It is a more open ended question than A and seems more useful than B. I don't see any reason for asking about her marital status or leaving the room and calling someone else.
5.C. Seems the nicest thing to do
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