We all feel pressure from not having enough time to care for our patients the way we want to.
Dr. Paauw
Organ recital
Some of our patients need to share an update on all their symptoms each visit, old and new, including those that are minor or possibly concerning. I have learned over the years that, for many patients, this allows them to release the worry about symptoms.
Some symptoms are so distressing and severe that symptomatic treatment is needed, but most aren’t.
I am very honest with patients when I have no idea what is causing their symptoms. I tell them, we will watch for other clues to see if the symptom needs a workup.
One thing I don’t do, and I strongly recommend against, is doing a review of systems. This leads a patient to believe you are concerned about exploring each possible symptom, ones that they didn’t even bring up! The yield is very low, and the time commitment is great.
The angry patient
Imagine a scenario when you are running 15 minutes behind and, when you step into the room, your patient is angry. You are already behind, and helping the patient navigate their anger will be part of your clinic visit.
In these situations, I always address the patient’s anger immediately. Problems with getting appointments with specialists, delays in diagnostic tests, or a broken entry to the parking garage have all been sources of my patients’ frustrations.
When we have limited time, using much of the clinic visit to process frustration leads to empty clinic visits. I listen and work to empathize with the patient, often agreeing that there are so many messed up aspects of the health care system. I do not like to use the corporate “I am sad you feel that way” response, because I feel it is not helpful. Instead, I tell them how much I want to help them today in any way I can at this visit.
The Internet sleuth
When our patients have new symptoms, some of them will go to the Internet to try to self-diagnose. Sometimes they make a correct diagnosis, but other times consider scary diagnoses we would not consider based on their symptoms and risk factors.
In these scenarios, I always ask the patient why they think their diagnosis is accurate. Their response to this question gives me insight into where their beliefs come from and helps me understand what information I need to provide.
McMullan said physicians can be defensive, collaborative, and informative when they interact with patients about information they have found on the Internet. In the first model, the physician is authoritative. The second involves working with the patient and obtaining and analyzing information. In the third model, the physician provides reputable internet sites to patients for obtaining information.
‘Oh, by the way’
Patients frequently bring up sensitive topics or complicated requests after the visit has wrapped up. Topics such as insomnia, erectile dysfunction, and anxiety are often brought up with the assumption that a quick prescription is the answer. For many years, I would add time to the appointment and try to address these issues as quickly as I could. But I invariably did a poor job at helping with these problems. Now, I offer to see the patient back soon to spend an entire visit discussing the newly brought up concern. I tell them that the problem is too important to not have my full attention and focus.
Pearls
- Empathetically listen to descriptions of symptoms, but don’t focus on fixing them.
- Empathize with the angry patient, and move on to taking care of their medical problems.
- Avoid the urge to address newly raised problems at the end of the visit.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose.