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Check out this blog post from Chris Worsfold. He always has good stuff.
http://www.chrisworsfold.com/on-opening-the-clinical-encounter/
What have you tried? Has it been successful? Does it change from patient to patient? Think you might try something different after reading this?
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This is a really interesting blog, and it’s well-timed for my personal reflection of my professional growth. I’ve been thinking recently about how I enter the room of an evaluation (a stranger) or a treatment session (someone I already have report with). I’ve wondered if it matters how rushed I was feeling 5 seconds beforehand, or what if it’s right after lunch and the first thing I do is yawn while sitting down? The blog is validating my curiosity, and it’s pushing it further.
Say a person has an inadequate view of what it means to have a disc herniation. Is it better to allow the person to continue to speak until their story dries out? I’d gain “ammo” to use later in my education and create a strong alliance, but I’d risk validating incorrect perceptions with apparent neutrality. I could do a stronger job of dictating the conversation, but I’d risk being just another doctor who’s expecting the patient to fit their agenda.
I love the the suggestion to just say, “Tell me what you think I should know about your situation.” I’d imagine it demonstrates a blank canvas for the patient to feel comfortable expressing their problem their way giving a strong sense of what the patient values and perceives is the crux of their problem(s). With this in mind, I may be able to answer my previous questions with the resolve to simply be a facilitator of their own narrative without dictating the outcome.
My big-picture observation is the incongruity of the direction of physical therapy practice and the direction of medical practice as a whole. It seems like there’s more and more emphasis of listening, being careful of verbiage used in front of patients, and letting a comprehensive subjective interview guide a well-established exam. On the other hand, medical practice as a whole is shrinking doctor-patient time. What’s obvious is that a more adequate subjective exam will lead to a more concise, more meaningful exam..
.. I’m curious what you all think is more important in the initial exam to gather, subjective (what the person feels might be occurring) or objective (what is definitely occurring) exam?
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Erik,
I think that the subjective is more important than the objective in the first visit. You can always continue to test and check different objective measures, but you only have one opportunity to make a first impression to begin the rapport process with your patient. I would actually argue that the objective aspect is the least important aspect of the initial eval. Sometimes I find myself rushing through my assessment, education, and prognosis with the patient because I spent all of my time on the objective. I am trying to make a conscious effort to stop doing this, because I think the most important things to do in the initial eval are:
1. Build rapport with the patient by showing that you care and listening
2. Reassuring the patient that they are going to be okay
3. Providing them with brief education about what you think is going on and how PT, and their participation in PT, can help their problem.Many times my opening line which is “what brings you to physical therapy today?” seems to backfire quickly, with the patient immediately spewing off a poorly understood but highly detailed and anatomically-driven reason why they are in pain. I have the same dilemma in my mind as Erik does. Do I interrupt the patient because I don’t want to validate their false understanding of pain? Or do I let the narrative continue and gather my information on their understanding of pain, to therefore educate them later? I think there is a middle-ground somewhere, but I’m leaning towards the latter. When it gets out of hand and the patient goes on and on and doesn’t stop, I’ll sometimes (gently) interrupt and mention that I have access to their images, so I can look at that later, but I would like to know more about their experiences and pain from their perspective. This seems to work well, because then the patient knows I will look at their image findings (I don’t always look) but then allows them to begin actually telling their story. My hope is that it gives them validation that I care about them as a person more-so than their MRI.
Something that surprised me was the stark contrast between how long the average time is until a PT interrupts their patient (23 sec) vs how long the patient will usually talk for if interrupted (92 sec). That is a huge difference! After reading that, I thought about how long I wait before interrupting my patient, and I honestly don’t know the answer (maybe AJ can tell you). I hope I wait more than 23 sec, but I definitely don’t wait over 1.5 min. The blog post seemed to allude that not interrupting the patient was the correct way to approach the subjective interview, but I wonder if there is any evidence beyond expert-opinion to confirm this? I don’t even know how they would test for that, but its an interesting thought for me.
The blog post stated that the most commonly used opening phrase was ‘Do you want to just tell me a little bit about your problem first of all?’ Does anyone else think this is strangely worded and too passive? After reading all of the opening lines in the picture, the one that I liked the best was “how can I help you today?” It doesn’t pigeon hole a specific body region, its open-ended, but also direct. Does anyone else have a different opinion? I’m also curious as to what your guys’ opening lines are?
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Jeff,
I read your post a little earlier, and I’ve been trying a few opening lines this week. I’ve had a lot of success with “Why don’t you tell me what you think I should know about what brings you in.” I asked a new patient this yesterday, and she outright said “The doctor told me I have bone-on-bone OA in both knees, so I honestly don’t know why we’re going to do an exam if you’re just going to give me a cookie cutter exercise prescription.” Boom, a boat load of talking points to start the session and not be bombarded with later on. It was such a nice segway early on without having to run my head into this halfway through my examination.
Try it out!
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Erik to your question, I agree with Jeff that a good thorough subjective examination is more important than objective information during the initial visit. As our understanding of pain and how psychosocial factors can affect its presentation, I feel that it is imperative to listen to the patient and their beliefs on what may be causing their symptoms. Listening to what the patient is saying (ammo) may affect some of the verbiage we use to discuss our findings and how we formulate our treatment plan.
In my short time of practice I have found myself opening conversations along the lines of, “why don’t you tell me a little of what is going on?” I have found this to be effective for some but others go on to tell me their entire life story and I feel the need to interject. Erik I have been trying to utilize the opening line you suggested as it is still open ended but provides more direction to the patient in regards to information we would like to hear in return.
Jeff I too was surprised at the average time a PT allows the patient to speak before interrupting. I’d like to think that I wait longer than 23 seconds before interrupting the patient but I have never timed myself. I have made a more conscious effort to shut up and listen over the past week allowing them to get their entire thought across even if it does not seem relevant to our conversation. I think this has been beneficial as the patients typically feel more respected not being interrupted and are more active listeners in return.
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My first line is, “So I just read your chart, but I want to hear from your perspective about what’s bringing you in here today with your (insert body region) pain”
– Some people will tell your their story (most people)
– Some people will say a one word response (“my back hurts” or “I have bone on bone”, etc)
– Some people will tell you anything and everything, not always related to their chief complaintMy response will change depending on their answer.
I try to acknowledge the patient filling their chart out because it takes people a long time (10-20 minutes). People will usually say, “Well I said that in my chart” if I don’t and lose rapport.
Eric and I have talked about asking open-ended questions at the beginning of the session, followed by more specific (but not leading) questions towards the end of the session. Sometimes I find myself asking leading questions to make the picture fit my diagnosis – this is something that I am currently working on.
The article also brings a great point of when do we answer after our open-ended question. What’s the point of an open-ended question if we interrupt immediately? This is something I struggle with as well. I have been trying to write down what they tell me initially and let them tell their story without interruption, then go back and ask specific questions about their story.
My main goal is to find out why they are coming into PT. I usually will end with something like, “lets say we get your pain better, what would you be able to do that you can’t do now (or scared to try) that you were doing before.”
Jeff, Erik, Matt – love hearing your responses on how you approach the subjective, awesome stuff.
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Cameron,
You had a lot of interesting points that I related to.
I too find myself asking leading questions so that I can fit a patient into the box I want them boxed in to. I think its because I am still uncomfortable with “gray” and we feel more comfortable when we can put our patients into a category. I am trying to learn to be okay that I may not know what is going on after the subjective, and even after the initial evaluation sometimes. However it then gets tricky to have the assessment and prognosis conversation with the patient to try and explain to them how you can help. Last week during mentorship, I told a patient I didn’t know exactly what was going on (non-specific chronic LBP), and this likely didn’t work well in setting up the patient’s confidence in me. AJ made a good point saying that I should have said something general like “your muscles and joint are stiff and overly sensitive, and we need to get you to move again to get you loosened up and to learn to like motion again.” Super basic and easy to understand from the patient’s perspective, and also doesn’t force me to give a specific diagnosis. It was a really good learning moment for me.
I like that you immediately acknowledge their chart to let them know that them filling out all that paperwork was worth something. I have been breaking out their pain chart like Casey suggested in another DB post, and I feel as though this has been very useful in mapping out their locations and pain complaints. Again, I think this is another way to make the patient feel like they are being listened to.
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