If You Were A Medical Student: How Would You Respond?
Think about being a 23 year old student who was in his or her first few weeks of medical school with the only experience in medicine as an occasional patient with a minor illness or having experienced the reactions to significant illness in the family. You are challenged in these early days of becoming a doctor to sit across from a real patient lying in a hospital bed and told to take a medical history with no immediate assistance by an instructor. When the history is completed, the instructor will discuss with you about your experience. You have already been instructed regarding the composition of the history though prior education of the details of how you should react to all situations which develop during the interview can never be complete. Therefore, when faced, at the time of the interview, with a decision of what to do or say next, what would be your response? As a student, how would you handle the following three scenarios? As the student's instructor, after the student tells you what happened, how would you support and further educate the student regarding the event? By the way, as an instructor, I have been informed about each of these three scenarios later as brought to my attention by students looking for advice. ..Maurice.
THREE SCENARIOS:
1. You are interviewing a 68 year old apparently competent woman patient with pneumonia and her 45 year old son is in the room who repeatedly interrupts your attempts to have his mother give the history herself by immediately responding with what he knows to each question. What would you do and what would you say?
2. You are interviewing a 33 year old red headed female flight attendant who is to have repeat right shoulder surgery by a different orthopedic surgeon because as she says the initial surgeon "botched the job". She says that she was left with more pain and limitation of motion of the right shoulder after the first surgery. She tells you what she knows about the surgery and her subsequent symptoms and then asks you directly "What do you think about how my surgeon treated me?" What would you then say to her?
3. You are interviewing a 28 year old female 3rd year medical student from a medical school in another state. She is very sick with leukemia and appears very weak, pale with multiple bruise-lie spots on her skin and is short of breath with repeated spells of coughing, raising bloody sputum as she tries to move in bed. She doesn't seem to be able to cope with her illness now and is very restless and depressed. She talks about her fear of dying and seems to be asking you, a first year medial student, to somehow give her some emotional support even though he had never met you before. You, yourself, are very upset about what you see and know. There is a "lump" feeling in your throat and you are beginning to feel nervous and weepy with tears welling up in your eyes. What would you do at this point and what would you say?
posted by Maurice Bernstein, M.D. @ 12:00:00 PM
6 comments
6 Comments:
#1. Maybe there's a reason. I used to be that "son". An elderly lady friend I cared for was completely mentally competant. Except at giving a medical history - she would completely mess that up, every time. Forget symptoms, forget medications, forget "minor" conditions like renal failure. She preferred I just tell the doctors what was going on (by the time we got there I had quizzed her thoroughly and gotten all the details) The doctors I got to know preferred that from us too. They could ask her more if they liked.
OK, that's probably unusual. But I would ask the son "You seem to want to answer my questions instead of your mother - why is that?" And also/instead ask the mother, "Do you prefer that your son answer my questions? Why?" Rather than trying to control the people, which generally results in them fighting back for control, I'd try to find out what's going on. If I'm getting the correct information from the son, and they're both happy with it, then that's their choice. If not, then by understanding motivations, perhaps that will make it easier for us to come to an agreement. Maybe say "Could I please ask your mother to answer me directly. Then, when we're done, I'll make sure you have the opportunity to tell me anything else you believe is important".
#2 "You do sound very dissatisfied with your previous surgeon and the results of your surgery. I wasn't there, so I don't really have much of an opinion. But I hope that we, and your new surgeon, will be able to treat you well here, and that your upcoming surgery will be successful." Acknowledge her feelings, and try to move on to the present.
#3 I have a harder time commenting here, as I am more comfortable with this kind of situation. But I guess the student could acknowledge her feelings, and admit that it makes him/her sad also. Say they can't imagine how hard that must be, at her age. I personally don't want a robot for a physician, nothing wrong with being human and having feelings. Nothing wrong, even, with saying as a young medical student, I'm not sure how best to help - what can I do? Maybe the patient will say what they need. Also, after listening a while, perhaps offer to send someone more experienced in if they'd like to talk some more - the chaplain, a psychologist, someone in hospice, to speak to the patient more.
TAM
TAM, you presented worthy responses. With regard to #1, even medical students have to be aware that there are parents who insist on being in the consultation room with their pre-teen or teen aged child to first "tell their own story" of the illness and to monitor what the child is saying. Parents may feel they have such a parental prerogative to be present and perhaps to talk first. But, the challenge for the student, is how to react and respond since students feel they don't have the same professional "clout" as a physician. Hopefully, by the time they become doctors they will have experienced the way to be kind and understanding toward such a parent, consideration of the privacy and a degree of independence of the child and have practiced a way to keep the history taking proceeding smoothly and productively. But it takes learning and experience.
Scenario #2- Sometimes, patients look to the consultative doctor or the medical student for their emotional support in such as situation as presented. And, in a reaction to "You do sound very dissatisfied with your previous surgeon and the results of your surgery. I wasn't there, so I don't really have much of an opinion", the patient may not understand how it is possible for another human potential patient such as the med student or doctor to remain ambiguous about the results.
With #3- The definitive and "not-to-be-forgotten" word that students and doctors should keep in mind in such emotional situations is to remain "therapeutic". Although emotional reactions should be expected to occur in every human who understands what another human is going through, those emotional reactions need to be consciously tempered so that the therapeutic value of the doctor-patient interaction is not lost. Sympathetic or even empathetic-based emotions expressed by the doctor or student may interfere with the subsequent communication and actions which would be of benefit for the patient. The concept is that if the doctor or the student is also suffering, necessary objectivity can be potentially lost. Doctors and med students can weep, since they are human, but that emotion must be consciously controlled. Agree? ..Maurice.
Thank you. I would welcome your suggestions for improvement. But here are my further thoughts.
Scenario #1, I am a little confused - you're speaking of a teen and a parent, but I think the original scenario was a 68-year-old patient? Or was the issue of a teen/pre-teen just meant to raise an additional scenario?
I think the teen scenario would be particularly difficult. Trying to not have the parent tell the story first is probably like trying to fight city hall - if they were determined, I'd probably tend towards letting them, or they will probably keep trying and/or become angry. Once they've spoken, hopefully then they'll let me ask the child some questions without interfering. If it's an issue that is sensitive, perhaps it would be better to try to interview the teen alone. What to do if the parent won't allow it? I suspect the physician is going to lose that disagreement, they are the parent after all. Not ideal, but I suppose it is their right.
#2 I doubt I would be able to satisfy that patient. She wants me to say her prior surgeon was an incompetant idiot butcher that should lose his medical license. But I don't want to say that. So I would try to talk sympathetically about how frustrating and upsetting it must be for her, without "bashing" the surgeon. She won't be satisfied, but at least I hope I'll have expressed enough sympathy/empathy that she won't be too upset with me and we can move on. Better ideas?
#3 I think sometimes realizing that the situation evokes some emotion in the physician IS therapeutic. No, they shouldn't break down sobbing hopefully, but I personally trust physians much more who show a bit of emotion, or some of themselves. If you're sooooo therapeutic as to seem like Mr. Spock, that's not an easy person to connect to. Nor trust as much, because it feels like such a physician just views the patient as a broken car to be fixed, and doesn't really care about the person - I don't want to feel like a science experiment, not a person. So I stand by my idea that some emotion is natural, and ok, there.
I also do not view a first year medical student as a physician. They're still kids. I don't expect the same from a first year student as a seasoned physician. I understand they're supposed to learn how to be, but they haven't yet. And that third year student knows it too. I think this scenario is over the head of the first year student, and they should be kind, admit some (hopefully controlled) emotion, and try to send her some more experienced people to offer support. Their need to learn is secondary to the needs of that patient. And everyone should know their limits, and when to ask for help.
TAM
TAM, sorry for the confusion about #1. I actually was suggesting a change of scenarios to one which is far more common and I am sure is regularly experienced by many general physicians and pediatricians. Who the student or doctor should talk to first really depends on the age of the child and the nature of the history to be obtained. Expressing and maintaining appropriate confidentiality is important regardless of who is interviewed first. A more "touchy" issue has to do with whether the parent should be present during the actual physical examination of a pre-teen or teen age patient. A lot has to do with the presenting clinical problem and most particularly with regard to the desires of the patient since the focus of attention should be on benefit for the patient.
Regarding scenario #2, many patients, hearing your defensive statement, would immediately assume you are simply attempting to defend a member of your profession. Since the patient knows the "facts", the patient would assume that the doctor could readily take those "facts" and come to an obvious conclusion. On the other hand, suppose this was not the first patient but the third to provide you with such an experience with that particular surgeon (and that is not so rare), would you confirm "other patients have told me the same" or would you proceed with the interview after simply expressing sympathy?
With #3, demonstration of true empathy by spontaneous "tearing up" is potentially therapeutic in that the patient gets a feeling that the doctor "understands" the patient's suffering. However, there is a point where the patient may look at the doctor's reaction as a sign of "loss of essential, professional control" and thus really non-therapeutic. It is what the doctor says and does next which defines that moment. ..Maurice.
Maurice, I posted an answer to this - was it lost?
TAM
TAM, every comment that you wrote has already been published but if you have a response to my last posting on May 15, please submit it again. ..Maurice.
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