Escaping/redirecting talkative patients

[flightdoc09]

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I'm a fairly soft spoken and respectful person and I've found that at times I have a hard time leaving a patient's room when things are really busy, or redirecting them to get back on the point of why they're hear. Younger patients aren't terrible, but with the older patients sometimes even if I try interrupting them they just keep talking.

I actually felt a little bad, as last week I had a really talkative 88 year old with a GI bleed. I avoided going back into her room to check up on her because things were super busy and I knew she'd keep talking. Was trying to coordinate IR/GI for her bleeding diverticula when she started coding. Ended up losing her.

But then other times, someone has a concerning EKG, and it's not so much escaping them but getting them to get to the point. Especially some of the older/farmer type gentlemen. They'll minimize, and hypothesize how it's probably just gas or something and go on some tangent about a friend who had gas that was scared it was a heart attack or something.

TL;DR - How do I get patients to get to the point and escape talkative ones without being disrespectful?

 

[oldtown]

 

[skougess]

“Sorry to interrupt, I have to check in on a critical patient.”

Then just walk out even if they are still talking. Done.

 

[namethatsmell]

If there's a piece of information you need and they keep going off on tangents, keep interrupting them as they stray in a y/n question structure until they actually answer: "Sorry to interrupt, but just so I understand..." Once you've gotten them into y/n mode, don't allow any dead air and keep up the urgency of your questions and they'll tend to stay on point.

If they fail on the 2nd or 3rd redirect (takes about 10-20 seconds total) time I just say "Alright I'm going get your orders entered to move your care along" and leave the room. There are really few things from the history we need to start an initial workup for most patients. And if need be you can always stick your head in their room along the way to ask a y/n clarifying question.

 

[thegenius]

Just politely interrupt them the way you politely interrupt anyone. They will understand. This will become quite easy as you get more experienced.

 

[Birdstrike]

I'm a fairly soft spoken and respectful person and I've found that at times I have a hard time leaving a patient's room when things are really busy, or redirecting them to get back on the point of why they're hear. Younger patients aren't terrible, but with the older patients sometimes even if I try interrupting them they just keep talking.

I actually felt a little bad, as last week I had a really talkative 88 year old with a GI bleed. I avoided going back into her room to check up on her because things were super busy and I knew she'd keep talking. Was trying to coordinate IR/GI for her bleeding diverticula when she started coding. Ended up losing her.

But then other times, someone has a concerning EKG, and it's not so much escaping them but getting them to get to the point. Especially some of the older/farmer type gentlemen. They'll minimize, and hypothesize how it's probably just gas or something and go on some tangent about a friend who had gas that was scared it was a heart attack or something.

TL;DR - How do I get patients to get to the point and escape talkative ones without being disrespectful?

I had an attending in fellowship. He was super quite, frail, and soft spoken. One time when rounding with him, we had a very difficult patient that was being irrational, cutting him off and giving his best "OMG! I NeED EVerY OpIATE UNdeR The sUN and WITHOUT LiMiT OR I'll DIE!!!" speech. Quite, soft spoken, Dr. Old School seemed to wake up from his slumber, put his cop-STOP hand up and said, very quietly, but firm, "Sir- sir- sir- sir- sir- sir- sir- sir-" seemingly with no end.

The patient prattled on, and Dr. Old School, never getting angry, kept on with the raised hand and, "Sir- sir- sir- sir-" both talking over each other for what seemed like an eternity.

Guess who won?

Dr. Old School. He won every time.

You're the doctor. You control the room. And you're going to do what you have to do, to do what's best for the patient. Try politeness, first, one time. It usually works. But if that fails and you have to cut someone off to do your job, do it.

 

[GeneralVeers]

I view the initial history as a meet and greet rather than a useful interaction. I do a cursory exam, ask a few seemingly important questions then excuse myself. Never ask follow up questions to a patient,'s story.

For times when I go back in the room with a difficult, time-consuming patient ill alert the nurse or PA that I want them to come get me with an urgent matter if I'm not out of the room in 5 minutes.

 

[deleted836128]

I legit tell the nurse to come in and get me or page overhead if I don’t come out in five minutes. They get a kick out of coming in the room and saying “ERCAT, you’ve got Dr Ballsac on the line” or paging overhead “ERCAT, proctologist on the line.”

 

[Angry Birds]

I do not take a formal history. I introduce myself and jump to physical exam. Then I ask a couple targeted questions. I then have one “long” (long for me) conversation prior to discharge.

 

[Tenk]

Set an alarm on your phone to go off that’s a beep like a pager after a few minutes and say: I’m being paged, I’ll be right back!

Protip: don’t go back.

 

[Groove]

You just redirect and politely interrupt like you would with anybody. I've started using the computer in the room to place orders and document while talking to them and have found this gives more time to "chat" and the pt's seem to appreciate it. When it's time to go, if they are still talking...I just tell them "Well listen, I feel like I could talk to you for hours. Let's get some of these orders completed so we can get you home! Otherwise, I'm afraid you'll be here all night!"

 

[TheComebacKid]

If I get the sense they are going to be a talker, i.e. nurse tells me they won't stop chatting etc, I walk into the room and open with. "So Mr. So and So, I already looked up your chart and know all about your past history, your cath last year with Dr. X, and that you take the following medications. I heard from the RN that you were having chest pain today, is that right?" That sort of disarms them, and makes them realize they don't need to tell me everything, but I can direct the conversation and the flow of the encounter.

This just stops the dreaded "Okay, so it all started 13 years ago when I went to the bathroom..." story. I don't even let them get to that point.

I think medical school really overstates how important history is. The vast majority of ED docs who have been practicing awhile already have a disposition somewhat thought out in their head from just reading the triage note. FOCUSED history is important, and helps you catch a couple of things here or there, but by and large, there's rarely I have spent more time in a patient's room and felt like "man, I'm glad I talked to them for a few more minutes, otherwise I wouldn't have figured this out."

I think most of us were taught in residency also, "Yes I understand you've had this pain for 20 years, but what changed about TODAY" line, which I still use and really helps me focus on the issue at hand.

I think sometimes ED docs are chastised by others in the house of medicine for "not taking a complete history", but I would argue that sometimes forcing the patient to tell you what you need to hear expedites their care, and quicker allows you to address life threats, as well as other patients in the department. I still remember in residency having a patient who had this long winded backstory for why she felt dizzy for the past several weeks, and how she recently changed her diet and all this other nonsense only to have her going into torsades and arrest in front of me.

 

[thegenius]

I think medical school really overstates how important history is. The vast majority of ED docs who have been practicing awhile already have a disposition somewhat thought out in their head from just reading the triage note.

Ehhhh...to an extent that is true. Sometimes an 8-10 minute history saves a tremendous amount of time and less testing vs. the 2 minute history of labs w/ a repeat lab 4 hours later. Anyway I bet we both agree with each other.

 

[flightdoc09]

What about when you try to redirect and ask a focused question and they're like "well just hold on a minute, I'm getting to that." Had an older lady do that to me the other day, luckily we were bed locked and I was seeing her in the waiting room anyways, so didn't affect my ability to move the meat that much.

 

[TheComebacKid]

Ehhhh...to an extent that is true. Sometimes an 8-10 minute history saves a tremendous amount of time and less testing vs. the 2 minute history of labs w/ a repeat lab 4 hours later. Anyway I bet we both agree with each other.

I think it's a fair point. And with certain chief complaints, perhaps you are right, more history is better.

I have found though that for the vast majority of patients I have a sense of what the plan is before I walk into the room. That doesn't mean that you aren't willing to change the plan after talking to the patient, or you aren't willing to stay a little longer to get more info. But for many patients, it doesn't matter what they say, they are getting labs, EKG, trops x2, CXR, admission.

Peds is one where I never know what I'm going to get. Many times I walk out doing nothing. Many times I walk in, see the kid, totally change things up and do a much broader work up.

Some of the vaguer complaints like syncope, weakness etc, I suppose you can chat a little longer. But I don't find that often the patient says something that drastically changes what I do, although you are right, sometimes it probably does happen. Part of the art is knowing when to ask more questions, and when the history isn't going to add much more.

 

[TheComebacKid]

What about when you try to redirect and ask a focused question and they're like "well just hold on a minute, I'm getting to that." Had an older lady do that to me the other day, luckily we were bed locked and I was seeing her in the waiting room anyways, so didn't affect my ability to move the meat that much.

Do other things while they are talking. Check for edema, touch their feet and feel for good pulses. Cycle through their BP again. Ask them for their medication list while they are talking. Or do what others do and chart/put in orders at the same time (I don't do this personally).

I think it's important to not come off as too distracted though. I think sometimes giving them 4 minutes of completely undivided attention makes them happier than spending 15 minutes in the room and listening to them talk about irrelevant things while simultaneously putting in orders and writing your note, etc.

You don't want to have premature closure, you want to get the correct information out of patients, but at the same time you want to predict where things are going ahead of time. This takes some fine tuning.

I also don't ask questions that I know the answer to. The chart clearly states they are on dialysis and what days they go and who their nephrologist is... For patients who aren't established sometimes you ask some more questions, but otherwise, it's redundant and wastes time.

 

[thegenius]

I think it's a fair point. And with certain chief complaints, perhaps you are right, more history is better.

I have found though that for the vast majority of patients I have a sense of what the plan is before I walk into the room. That doesn't mean that you aren't willing to change the plan after talking to the patient, or you aren't willing to stay a little longer to get more info. But for many patients, it doesn't matter what they say, they are getting labs, EKG, trops x2, CXR, admission.

Peds is one where I never know what I'm going to get. Many times I walk out doing nothing. Many times I walk in, see the kid, totally change things up and do a much broader work up.

Some of the vaguer complaints like syncope, weakness etc, I suppose you can chat a little longer. But I don't find that often the patient says something that drastically changes what I do, although you are right, sometimes it probably does happen. Part of the art is knowing when to ask more questions, and when the history isn't going to add much more.

Yea man I agree. My history taking has been cut in half, at least, over the past 5 years.

I think GI bleeds is one area of potential discharge. Someone can say "I'm popping blood" and there isn't much more you need for the history. You get labs and admit. But a good history will suggest it's low risk, get a CBC/BMP and discharge. Anyway...we are in agreement

 

[thegenius]

What about when you try to redirect and ask a focused question and they're like "well just hold on a minute, I'm getting to that." Had an older lady do that to me the other day, luckily we were bed locked and I was seeing her in the waiting room anyways, so didn't affect my ability to move the meat that much.

This happens rarely...most of the time I say "I think your history here is really important...but I need an answer to a few key questions and I'll come back later and get that history". And of course I don't come back.

Once every two weeks you'll get a talker, no matter what. Kind of hard to avoid overall.

 

[dadaddadaBATMAN]

What about when you try to redirect and ask a focused question and they're like "well just hold on a minute, I'm getting to that." Had an older lady do that to me the other day, luckily we were bed locked and I was seeing her in the waiting room anyways, so didn't affect my ability to move the meat that much.

I almost uniformly interpret this as a sign of mild-moderate dementia. If they require that much context to remember the answer to a simple question they are probably not giving you a worthwhile history.

I just interrupt them again and ask them the same question with the preface “this is really important.” If the yammering resumes I physically interrupt them, either by holding their hand with a light squeeze (I wear gloves everywhere) or by grasping the wrist gently and tapping on it with my other hand, and then ask again.

If these three fail I usually make a polite excuse and either bow out or walk out depending on how persistent the yammer is. Then I read the nursing triage note that is usually a near identical story Because dementia, and call a relative/snf for collateral if I really need more history.

 

[Saddleshoes]

I rather like the banter with patients.
I find, I can usually use their own words to create an exit for myself. There is an art to it, which I have refined over the years. BUT you beginners look into this book...

 

[Angry Birds]

Ehhhh...to an extent that is true. Sometimes an 8-10 minute history saves a tremendous amount of time and less testing vs. the 2 minute history of labs w/ a repeat lab 4 hours later. Anyway I bet we both agree with each other.

8-10 minutes lol

 

[thegenius]

8-10 minutes lol

HAHA
at the end of the day, I'm one of the lowest CT utilizers in our group, and I would like to think that my outcomes are as good as everyone else.

There are many ways to skin a cat. (Isn't that a phrase?)

 

[Brigade4Radiant]

Physical exam is mosly worthless in most patients.

 

[emergentmd]

Didn't read the thread but I can only speak for my experience.

1. History and physical and useless in 90% of the patients.
2. I start with what brings you here. They give a quick answer. I start with a 4-5 pointed question then exam.
3. My physical is much more important than my history and usually focused. If you have currently having the worse abd pain of your life and your exam is benign while texting on the phone, then doubt I need much more history b/c you are unreliable

I will say I spend less than 5 min in the room in 95% of patients.

I have had 2 patients in the past 3 yrs where when I walked out, the nurse was concerned that there was something wrong. 1 patient was an old friend and were catching up. The other patient was telling me about working overseas and the benefits.

I will have 1 out of every 10-20 pts where the history/exam is squirrely and I double back for a more thorough history.

 

[Rendar5]

“‘Sorry to interrupt but just so I’m clear on this, what would you like to happen today,’ or ‘what would you like me to do for you’”. Usually they stop and you can focus them after you get an answer.

Then if they can’t focus again in your brief directed history, just excuse yourself. Either accomplish what they wanted or manage expectations.

Only for talkers. People who are reasonable actually do get a proper history from me. Proper history is done in less than 5

If you know why they’re there you save a ton of time on testing and disposition and can be rude and stop the banter safely without the next day complaints. , Be careful assuming you know why they’re there. Cut them to the chase.

 

[Restart13]

The real question is how do you avoid annoying and talkative staff that sit right next to you all night?

 

[GassYous]

The real question is how do you avoid annoying and talkative staff that sit right next to you all night?

Earplugs