Professionalism Part 4: The patient encounter
Here are some "do's and dont's" when a patient is seen in an outpatient setting. In-patient encounters should ideally follow the same principles, although the circumstances may dictate the conduct of the interview and the examination.
Do's
Do arrive on time for your appointment.
Do dress professionally (see previous weblog for details).
Do review all the relevant notes and investigations PRIOR to visiting with the patient. Speak to the referring clinician, if possible. This may save invaluable time and may clarify the question to be answered by your consultation, in addition to providing insight into the clinical case. It is professional to appear knowledgeable and informed about the patient's condition. Shuffling through papers and being unaware of results while speaking to the patient and their family does not instill confidence in you as their surgeon.
Do introduce yourself and state your title; do the same for anyone accompanying you.
Do shake the patient's hand and aswell as family member's. This acknowledges everyone's presence.
Do sit down.
Do allow the patient to speak about their problem. You really should already know what their problem is and this is mostly for the patient's benefit. However, this may give the surgeon a sense of the severity of the symptoms, which is important in your clinical decision-making.
Do examine the patient. The laying-on of hands is expected from a doctor. Again, this is mostly for the patient's benefit, although it may actually be useful in certain clinical situations.
Do explain to the patient what the problem is and what can be done about it. (Teach them and be better than the internet.) This "counseling" is the main purpose of the visit and most of the encounter should focus on this (including informed consent). In fact, in cardiothoracic surgery, the surgeon needs to spend little time obtaining new information from the patient (other than to get his/her own sense of disease severity). If the physician has done his/her job, all the relevant clinical, laboratory, radiological, and pathological information are already elucidated and available.
Do draw a picture.
Do show the films to the patient, if possible and practical.
Do use understandable language for the patient and their family (a platitude).
Do answer all their questions. This is a simple statement, yet it is perhaps the most important aspect of the whole patient encounter.
Do obtain true informed consent.
Do allow the patient to end the visit when they are satisfied that all has been explained and all questions have been answered.
Do have a clear plan that they understand and a concrete next step for them to take.
Do shake their hand as you leave.
Do say you are available to meet again and answer any other questions, if required or desired.
Do dictate a note immediately after the visit.
Dont's
Don't arrive late. If so, say "I am sorry to keep you waiting". Explain that you had an emergency to attend to. No one can argue with this.
Don't stand.
Don't review the clinical record while interviewing the patient, except to specifically check a point of discrepancy that surfaces during the encounter. You should be familiar with the case PRIOR to visiting with the patient.
Don't answer the phone or pages during the visit, unless they are emergencies.
Don't do any billings, bookings, or any other paperwork during the patient visit, especially while the patient is asking questions. The patient should perceive that you are focused on them during the entire encounter, without being distracted or preoccupied by anything else.
Don't get up to leave until the patient signals that they are satisfied and ready to leave. If you have already gotten up and some other question comes up, close the door, take your hand off the door knob, face the patient and answer the question.
Don't gloss over informed consent. I have seen surgeons gloss over and rush through the informed consent process. This is a recipe for disaster.
Don't rush, even if you are in a hurry.
Don't put your hands over or on the back of your head.
Don't take any abuse from the patient or their family. If this happens it is your perrogative to end the interview and dismiss them. Your only responsibility is to ensure they have adequate follow-up elsewhere (usually back to the referring or primary MD).
Don't call patients by their first name.
Don't allow them to call you by your first name.
A few final thoughts:
Excess of time is not a requirement to achieve the things stated above. I have seen all of the do's and don'ts accomplished in 20 to 30 minutes and I have seen them violated in one entire hour. Also, "niceness" is not a priori. In fact, all I have stated is more about respect, politeness, and professionalism than about being "nice" and overly friendly with the patient. Again, I have seen the "nicest" surgeons perform some of the worst mistakes during patient interviews. Patients and their families will respect you for your knowledge, skill, expertise, and professionalism. This will gleaned from your interaction with them when you meet for the first time.
Do's
Do arrive on time for your appointment.
Do dress professionally (see previous weblog for details).
Do review all the relevant notes and investigations PRIOR to visiting with the patient. Speak to the referring clinician, if possible. This may save invaluable time and may clarify the question to be answered by your consultation, in addition to providing insight into the clinical case. It is professional to appear knowledgeable and informed about the patient's condition. Shuffling through papers and being unaware of results while speaking to the patient and their family does not instill confidence in you as their surgeon.
Do introduce yourself and state your title; do the same for anyone accompanying you.
Do shake the patient's hand and aswell as family member's. This acknowledges everyone's presence.
Do sit down.
Do allow the patient to speak about their problem. You really should already know what their problem is and this is mostly for the patient's benefit. However, this may give the surgeon a sense of the severity of the symptoms, which is important in your clinical decision-making.
Do examine the patient. The laying-on of hands is expected from a doctor. Again, this is mostly for the patient's benefit, although it may actually be useful in certain clinical situations.
Do explain to the patient what the problem is and what can be done about it. (Teach them and be better than the internet.) This "counseling" is the main purpose of the visit and most of the encounter should focus on this (including informed consent). In fact, in cardiothoracic surgery, the surgeon needs to spend little time obtaining new information from the patient (other than to get his/her own sense of disease severity). If the physician has done his/her job, all the relevant clinical, laboratory, radiological, and pathological information are already elucidated and available.
Do draw a picture.
Do show the films to the patient, if possible and practical.
Do use understandable language for the patient and their family (a platitude).
Do answer all their questions. This is a simple statement, yet it is perhaps the most important aspect of the whole patient encounter.
Do obtain true informed consent.
Do allow the patient to end the visit when they are satisfied that all has been explained and all questions have been answered.
Do have a clear plan that they understand and a concrete next step for them to take.
Do shake their hand as you leave.
Do say you are available to meet again and answer any other questions, if required or desired.
Do dictate a note immediately after the visit.
Dont's
Don't arrive late. If so, say "I am sorry to keep you waiting". Explain that you had an emergency to attend to. No one can argue with this.
Don't stand.
Don't review the clinical record while interviewing the patient, except to specifically check a point of discrepancy that surfaces during the encounter. You should be familiar with the case PRIOR to visiting with the patient.
Don't answer the phone or pages during the visit, unless they are emergencies.
Don't do any billings, bookings, or any other paperwork during the patient visit, especially while the patient is asking questions. The patient should perceive that you are focused on them during the entire encounter, without being distracted or preoccupied by anything else.
Don't get up to leave until the patient signals that they are satisfied and ready to leave. If you have already gotten up and some other question comes up, close the door, take your hand off the door knob, face the patient and answer the question.
Don't gloss over informed consent. I have seen surgeons gloss over and rush through the informed consent process. This is a recipe for disaster.
Don't rush, even if you are in a hurry.
Don't put your hands over or on the back of your head.
Don't take any abuse from the patient or their family. If this happens it is your perrogative to end the interview and dismiss them. Your only responsibility is to ensure they have adequate follow-up elsewhere (usually back to the referring or primary MD).
Don't call patients by their first name.
Don't allow them to call you by your first name.
A few final thoughts:
Excess of time is not a requirement to achieve the things stated above. I have seen all of the do's and don'ts accomplished in 20 to 30 minutes and I have seen them violated in one entire hour. Also, "niceness" is not a priori. In fact, all I have stated is more about respect, politeness, and professionalism than about being "nice" and overly friendly with the patient. Again, I have seen the "nicest" surgeons perform some of the worst mistakes during patient interviews. Patients and their families will respect you for your knowledge, skill, expertise, and professionalism. This will gleaned from your interaction with them when you meet for the first time.
posted by Luis G. Quiñonez, M.D. at
7:36 PM
1 Comments:
I really appreciate your clear presentation. Especially the "do and don't" list. It speaks of a future manual in the works!
Really! I'm happy with this one: While it might still approximate all my previous criticisms on your hegemonous and surgeon focussed approach (which I guess is a 'natural' thing), it nicely displays your sensitivity to peoples' needs (even if none of it means being 'nice').
I am now 100% confident of your clinical acumen.
:)
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