I struggled with this the most as med student, and had to learn brutality in residency
Luckily with residency, you will walk into the room with a palpable aura of stress, pressure, rush, urgency and you will even be talking faster as a result, when you think about mirror neurons, all these things a patient can pick up on.
One of the first things I say is, and it comes off as a well practiced rattle (yours too will with time)
"Hello, I'm student doctor ___ and I'll be helping you today. As I understand it, you're here for ___ today" (you almost never go in cold without a CC) [doesn't matter if it's wrong, and actually, don't let the patient interrupt you to correct, this "steamrolling" you're doing at the start is setting the tone]
"I apologize ahead of time if I seem curt & keep interrupting you a lot, I don't mean to be rude, and it's not that I don't care about what you have to tell me, it's just that we have a lot to cover so I can be sure to get all the info I need to help you best, so we can get you feeling better as quickly as we can. So tell me about your ___, [insert follow up question that's yes/no] Example: "Tell me about your chest pain, are you having shortness of breath?"
If the CC is totally of, or the SOB has nothing to do with CP, here they can correct you.
(RE: my intro speech:
One of my fave lines about being a doctor from med school: it's all about managing expectations. Never forget that.
1) before you have had a chance to offend the patient you've apologized
2) you've given them an "expectation" of what your behavior is, and given a very benign reason for it
3) you've reassured them you care
4) if they bristle at being cut off, reassure them that there will be a chance to tell you whatever they want AFTER you get what you need
I remember being taught, that most patients are used to this "transactional" style of communication from doctors. Even the way that you see a personable ED doc take a history, if you were to say, use that style with your spouse's Gramma at Sunday dinnner... well no one would talk to a friend that way.
You have to learn a NEW way of communicating that is basically unlike any other normal way of communicating that you have learned to date.
It's an interrogation, and most patients understand that, especially from doctors.)
I give a little more leeway for HPI. Still, I go in with a mission:
OLD CARTS
have you had ever before, what did you try/take at home
ROS
PMASF
It's written on my paper, it's in my template note.
For HPI/OLD CARTS
I have to ask and feel satisfied in what I get about each one before I "allow" the patient to tell me more.
Each one might raise more questions I have, and if a patient is telling you stuff that is useful, ie: is fill great.
It doesn't have to be in order. You get used to jumping around as data comes out of their mouth.
But having the above letters on my paper I can just fill out the form as they go and I'm less likely to forget stuff.
If you're in a computer, you might have to be more rigid about cutting them off and having them answer your questions as you ask them.
For any CC, I have a series of pertinent positives, negatives, and questions that need to be asked. Learning those will template your interaction. They will also let you know if you need to go down a different pathway re: the CC. You get better at knowing the specific set of questions for MI vs PE vs COPD exacerbation vs heartburn vs aortic dissection vs pericarditis vs ....... which helps you extract pertinent info from patients.
For CP, I have to ask about SOB, quality of pain (pressure), radiation. There's a lot more, but if 2 of 3 are positive I can't remember the PPV for MI, but it's super high. So I gotta cover those FOR SURE before we talk about any of the tangents that might come up related to those questions. Of course I need to ask n/v, etc re: CP.
When I get to ROS, the stuff that I wasn't super excited to know in uber detail re: CC
I tell them "I'm going ask you a bunch of yes or no questions,"
If they give me a yes, you learn how to ask follow up questions to get to more info re: vision that you care about.
If you go in with a mission of fill in the blank, checkbox, and you try to fill them in order, and you are get good at little filler things to say before just cutting someone off and asking your next question, you will get more efficient.
In a way, I would do the oppositite of what you're taught:
Start off with an agenda, pertinent pointed questions
ask a lot of yes/no questions, and THEN depending on what you catch, go from closed --> open
If what they are telling me sound medically pertinent but wasn't what I asked, that's fine.
If I know it's truly meaningless, "No, I'm not having any CP. Speaking of chest pain, my neighbor has to--"
I IMMEDIATELY SHUT THAT DOWN. In that case I don't even segue, if the first part I got what I wanted and now it's this, I immediately go for the next data point I want. "Are you having any SOB?"
As a med student, I wasn't always sure what info I even needed. I kinda had to be a human wastebasket of questions and drivel just to start learning how to weed through it and what to ask. As you get better at CC: and what you need to know, you will learn to go in a room and just extract it with rapid fire questions. You won't sit there trying to think, "what else should I ask?" you'll walk in already with 20 questions, and every answer you'll know what 5 follow up to do.
Doing some ED rotations REALLY helped me learn this. Coffee can help too.
1 phone call:
I probably look either annoyed, or I point to the door and mouth, "would you like me to go?"
Usually this gives a clue it's rude and I don't have to leave.
I probably have talked to them enough to have some stuff to write on my paper/EHR so they usually are not wasting my time.
However, when they get off the phone, I am likely to say, "Oh I'm sorry, would you like me to go?"
If you get anything other than an answer you like, you can always add, "it's OK, I can step out, it just might take longer for you to be seen by ___insert superior/get care if we don't continue through this in a timely fashion. I need to know as there are other patients waiting as well."
Not rude, but you're outlining consequences for wasting your time and they will be more likely to silence the next call.
If they don't now it's call 2, then you really should walk out, even if for just one minute for show. This is not bad doctoring. It really is to their benefit to prioritize this interview and you are not benefitting the patient by making this behavior OK, so it is for them, not you.
If they had me leave the room the first time, when I come back, I might say, "I think it's really important that we get through this interview to get you care in a timely fashion. Do you think we can continue uninterrupted?"
If all of the above isn't enough pressure to get them to quit with the phone, I don't know what to tell you.
IRL if the patient was not having an emergency, and you were not a student, the physicians would basically leave the patient for as long as was not harmful to workflow to go do other work, and basically forget them (barring safety).
If it were the ED or a more urgent situation, you could be much more blunt, and say, "I am trying to make sure you're not having a life-threatening emergency. I'm going to have to ask that for your own safety that you silence your phone until I can finish talking to you and make sure that you're safe. Once we know you're safe you can let other people know."
TLDR:
Start with my opening speech at the top
Don't be afraid to interrogate, interrupt
Go in with a mission and a list
