We now come to Part III of our discussion on “Preparing for the Step 2 CS” In Part I, we discussed how to prepare for the medical interview part of the clinical encounter. In Part II, we discussed the physical examination part of the clinical encounter. We will now tackle the social aspects of the clinical encounter which is usually called bedside manners.
We can further divide the social aspects of the clinical encounter into two. Those that you do in every clinical encounter and those that you do in specific situations. We will start with the first one.
So what are the things you do in every clinical encounter?
When you are at your station, the doorway will contain the name and chief complaint of the patient inside. Take note of it, writing it on the upper right side of the page so you do not forget the patient’s name or get it wrong. Knock on the door, then open it. Greet your patient. Use good day or hello, rather than good morning or good afternoon to avoid making a mistake (wrong time of dayJ) Introduce yourself. It’s best to be formal like ” Hello, Mrs. Jones, I’m Dr. Uy, How may I help you?” Then followed by a question. Other variants could include, “What brings you to the hospital today?” or ” What seems to be the problem?” Try to use the phrase that is easier for you to pronounce.
If you got a patient who likes to joke and answers “The bus” or “by cab” when you ask them what brings them to the hospital today, Just give him or her your widest smile and rephrase the question, like “How can I help you today?” You should not ignore them, nor join in the joke but keep the interview going in the right direction.
Now where do you position yourself for the interview? It is important to make sure that you face the patient as much as possible during the interview. It is also important that you are either at the same level as your patient or lower. Usually the patient is sitting on the examination bed and it is alright to be standing up as you will be level with them. However, occasionally they’ll be sitting in a chair and it is advisable then to sit down too. Always look at them when speaking to them and do not let your eyes wander around as that is impolite. Avoid any situation where you tower over them and they are forced to look up at you as that is considered impolite. The only exception is during the physical examination when they are lying on the examination bed.
It is good practice to ask open-ended questions during the interview. The main reason is that, by asking open ended questions, the patient will volunteer information you might miss if you answered close-ended questions that could be answered yes or no or with short answers. For example, it would be better to ask her “Could you describe the pain?” rather than ” Is the pain throbbing or stabbing?” etc. Only when she gives a vague answer, do you ask more close-ended questions. Although, I’ve read in some forums about patients going out of tangent when asked open-ended questions, my own experience is that they are professionals and would not deliberately waste your time by giving irrelevant long winded answers.
Never, hurry the patient, nor cut them short in their answers as that is rude and impolite. In the exceptional case where you have a patient who is giving you the run-around with their answers, then gently tell them that you would like to know more about this particular illness. Remember, in all probability when they do that, it is part of the test to see if you can recover gracefully when a patient starts talking about things irrelevant to their presenting case.
It is very important to show care and concern for the patient and empathize with them. For example, if the patient said something like, their parents had died, you should say ” I am sorry to hear that.” Or if they said that they missed playing golf because of their current ailment, you can say ” well, we’ll try our best to make you better, so you can go right on back to doing the things you like.” There are a lot of other situations that can happen and we will talk about them in detail and the proper responses you can take later.
It is also very important to give proper medical advise when the patient gives you information about them. Example includes, smoking, drinking, safe sex, contraception, child safety, etc. We will discuss in more detail under specific circumstances. Now the question arises, when do you give medical advise? Although some people prefer to give it before closing the interview or even after the physical examination, personally, I think it is best to do it immediately after such condition comes up in the interview. For example, if the patient mentions she smokes, then give counseling immediately. The reason is so that you get the easy points immediately. If you wait for later, you risk the chance of forgetting or running out of time and lose easy points.
Throughout the interview process, it is important to use transitions sentences not only to ease the conversation along, but as a means of building rapport and showing concern for the patient. For example before proceeding with LIQORAAA, you may say, “I’d like to ask you more about your present problem, is that alright with you?” When transitioning to the Past Medical History (PAMHUGSFOSS), you can ask ” I need to know more about your past to better understand your current illness, is it OK if I ask you some questions?” Now, when going into the Personal and Social history as well as sexual history, you can say ” I am going to be asking you some personal questions about your lifestyle and sex life, is that alright?” Doing these are just being polite. Now in real life, you will have patients who will object, but the simulated patients will always say yes. Even the supposedly depressed patient I had said yes, when I was expecting him to object.
Now the biggest transition is when you finish the clinical interview and would now be proceeding to the physical examination. It is important to take this opportunity to ask the patient if he would like to tell you anything. You could say something like this ” I am now going to examine you physically in a little while, is there anything that you would like to tell me, or I may have missed about your current condition?” Sometimes, you may be surprised when the patient gives you additional information you forgot to ask. You can then continue the interview a little while to make sure you completed the information. Now, if the patient says that you’ve covered everything, say “Thank You for your cooperation, I’ll just wash my hands and we’ll start the physical examination”
Now we come to the issue of hand washing. Now the question is, which is better, to wash your hands or to wear gloves? You will read in a lot of forums that people to chose to wash their hands because it is faster. However, in reality it isn’t and the time difference is not too much if you are experienced in wearing gloves. I wore gloves in all my cases.
Don’t get me wrong I started out with the intention of washing my hands. However, I took my CS on March in Los Angeles and the weather was quite cold. Being from a tropical country, I started peeling. It was especially bad on my hands. It was actually embarrassing as a co-examinee tried to wipe away what he thought was a piece of tissue from my cheek. Instead it was actually skin peeling. And so washing my hands would not only make it worse, but some parts of my hands were raw and my fingers bled easily with minimal trauma. So I wound up wearing gloves instead. So instead of being tied to the sink, I would be walking back to the patient, giving him instruction on what to do while putting on the gloves.
Now, washing your hands also takes up a lot of time. First you wet your hands, then you put on soap. Next you have to wash off the soap completely. Then you have to dry your hands. Plus your hands will be cold and you need to warm them before touching the patient. That takes time. Some people advocate to just simulate the handwashing, Barely wetting your hand. Letting the soap fall to the sink instead of actually soaping your hands. Then wet your hands again, so it is easy to dry off. That will save time. But I do not know if they take off points if you do that.
But taking off the gloves again takes time, you say. Not really, in one case, I took the glove with me right out of the examination room and left it on the table while writing the patient notes. The proctor actually told me to just leave it on the table. So take it off only if you have time. If not just walk out with it.
Now what do you say to the patient in the moment that you are washing your hands or putting on your gloves? The silence can be awkward so it is better to fill it with conversation. If the patient is on a chair you can instruct him or her to sit on the examination bed. Most of the time, the patient will be on the examination bed and you can use the time in small conversation to increase rapport. For example, if the patient tells you he likes to play golf, ask what his handicap is. Or if she talks about her grandchildren, ask her how old they are and how they are doing.
We will continue next time on social manners during the physical examination including the all important draping procedures. We will then cover specific situations during the clinical encounter and what you should do about them. Then to patient notes.