Learning Bedside Manner

[Blanch]

Dear Abbey,

I bombed my first patient interview for my schools Doctor Patient Relationship class and am feeling pretty lousy about it. You're probably thinking, how on earth could you bomb something like that... I guess I just got really nervous. The guy didn't seem like he really wanted to be interviewed in the first place, so I just didn't feel comfortable asking all kinds of personal questions. One of my questions about the patients feelings towards his illness caused him to break down. This made me even more nervous and lets just say I handled it very poorly... didn't wait long enough before continuing, started going all over the map with my questions, and eventually got "shut out" so to speak. I walked out feeling like I was hit by a freight train. And then the feelings of failure, why am I here, how am I ever going to be a doctor started creeping in. It's really kind of embarassing, not to mention the negative eval that I'm going to have on my file from it.

How can I work on this? Has anyone else had such a lousy first interview? Does it just take a little more practice? Am I doomed to be a pathologist? Thanks for your advice.

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[Street Philosopher]

Was this with a real patient?

 

[redleft123]

Dear Lost-at-the-Bedside --

RELAX! At one point or another, we've all had this happen. I can remember my horror bedside tale!

Some of us freeze up at exam time, others during interviews. For you, it was all rolled into one ... interviewing a patient for class ... and while it may not have been the best day for you or the patient, think of it as a learning experience. And next time, just treat it as an everyday conversation.

Once you've gone thru impacted colons, puking patients, OD patients, STDs, etc, a bedside visit will become a boring every-day event.

Abby

 

[DrQuinn]

Blanch-

Fear not. Everyone has their own personal bedside manner. Some better than others.

But that doesn't mean you can't improve on it. I think the biggest way to improve on your bedside manner is to:
A) Learn to LISTEN
and
B) Understand that body language and tone of voice are a BIG part of bedside manner.

I am an EM resident... so my interactions with the patient are only but a few minutes... and I have to build rapport very quickly. Here are some tips that I have learned through my whole 3.1 months of internship (and four years of medical school):

1). Always introduce yourself. "Hi, I'm Blanch Smith, student physician." "Hi, I'm Dr. Quinn X, one of the Emergency Medicine residents here." Use your full name. You'll seem more human, and less on a pedestal.

2). Always shake their hand. If they don't have a right hand, shake their left.

3). Start with an open ended question (after all the niceties)... what brings you here today?

4). SIT! Sitting down (even in the Emergency Department) gives the patient the illusion that you were in the room longer. A lot of my patient encounters are less than a few minutes (we do relatively focused HPIs in the ED), so to maximize the impression that I am spending more time with them, I'll often sit down on a stool or chair, or at the edge of their bed (if its ok with the patient).

5) Always, ALWAYS, ask if there are any questions. Most of the time the patient won't have any (surprisingly... this can be for two reasons, either you explained what's going on well (which is what i hope is usually the case) or they just don't care). If the patient begins to ramble on and on, learn to exit quickly but tactfully.

6). Delivering bad news or being the listener to someone pouring their heart out is TOUGH. That is definately not easy. You'll beocme better with it through time, I promise you. Each physician/med student handles it different. Some are very touchy feely, some are not...

Q, DO

 

[ERMudPhud]

I have to agree with Quinn. His/Her stated style is almost exactly the way I approach patients for the first time. Especially the sitting down part and asking them if they have any questions or concerns. I also ask the rest of the family present if they have any questions.

In terms of getting used to medical interviewing. It's always ackward when your first doing it, especially if its a fake patient or you are being watched and graded. The key is to just do it so many times that it becomes easy and second nature. Repetition is the key here. As your knowledge base increases you won't find it as hard to come up with questions either, since, you'll know what else you need to know. Your questions will also become more focused Right now in addition to feeling under the spotlight your mind is racing trying to think, "what the hell else do I need to ask him?" My first patient interviews were painful experiences and watching my classmates were equally painful. It gets better.

As for the "blackmark" in your file don't worry so much. We did our first patient interviews in psych during first year and the whole situation so contrived that I really didn't feel I got much out of it. I ended up getting a note in my file from my psych preceptor that I had terrible patient rapport and should probably be locked into the lab. The truth is that he and I had terrible rapport. I ended up honoring many of my third year rotations(including psych) and consistantly got high marks for patient interactions

P.S. patients seem to like me fine now

 

[Al Pacino]

I feel the original poster's pain. I'm a third year in OB/GYN, and I've bombed some of the pt interviews. In my labor and delivery rotation, you follow two types of patients: clinic and private. I have no problem going in and talking to the clinic patients and feeling like I belong such that I eventually participate in the birth process. But with the private pts, I get really nervous because I feel like I shouldn't be there. Some of the private pts have made it clear that they don't want students involved in their birthing process, which makes me even more nervous.

 

[Blanch]

Thanks for your thoughtful responses. I definately learned a lot from the experience, perhaps more than if it had gone perfectly smoothly. It was a real patient and I have several more chances before the class is over, so hopefully I'll have a better idea of what to expect next time.

 

[Adcadet]

my wife is a paid patient at my medical school. She says that nearly all students (MS2's) are horrible in one way or another.

Just remember, if this were easy, everyone would be doing it!

 

[KyGrlDr2B]

Originally posted by Adcadet
my wife is a paid patient at my medical school. She says that nearly all students (MS2's) are horrible in one way or another.

Just remember, if this were easy, everyone would be doing it!

And if it were easy, there wouldn't be a class taught on it.

 

[Starflyr]

You know, Im just ending my family practice rotation, and it took me utnil this month to get used to interviewing patients. Now, I feel pretty comfortalbe with it - but it took me being in clinic from 8-5 5 days a week seeing 10-15 patients a day to get here. I still have trouble with being quick, sometimes, since I always feel as though I need to ask all the questions - ROS, family history, etc etc etc....even though I dont (Im just terrified Ill leave something out). Im getting better at not having to do that, though. I just have to remember to ask about the (&*#@$ mammograms. I ALWAYS forget that! EESH!

No fears, you'll get better when you meet patients who are YOURS, who you have a hand in treating. Especially since you're a MS 1 or 2, if you're interviewing a real patient in the hospital, EVERYONE has priority over you - we had to do that MS 2 and wow, even lunch took priority, and the nurses ordered us out after a 5 minute interview (to base a H&P on). Nobody expects you to be good at it yet.

Star

 

[DrQuinn]

Originally posted by ERMudPhud
I have to agree with Quinn. His/Her stated style is almost exactly the way I approach patients for the first time. Especially the sitting down part and asking them if they have any questions or concerns. I also ask the rest of the family present if they have any questions.

Hhaha, his/her...

Anyways, what the big point of this thread is, that it takes a LOT of practice.

At my medical school, NSUCOM, they taped our "fake" patient H&Ps... and I remember watching the first one, and it was horrible... it looked like I was interrogating a terrorist (minus the swinging light). Now, I don't even really think about it...

BUT! When I was a first year on my preceptors, I was pretty nervous seeing patients, and even the first few times on rotations... but after a few weeks, months, and rotations, you'll get comfortable.

You will ALWAYS get the "I don't want a medical student seeing me" no matter where you go. I wouldn't mind letting a medical student see me, but that's different. By the end of your fourth year it gets even older to have to be turned away by the patients. But once internship rolls around (and you are comfortable seeing patients) you'll pretty much be able to do whatever you want.

(BTW, I do not know one intern that I've met that has had trouble with patietn interactions... so that's good news! Everybody starts off slow but in the end we're all on the same page)

However, I have met people who have HORRIBLE bedside manner, and lose their temper quite quickly with patients (stereotype to follow: Surgeons (but most definately not all)). Thankfully, none of my fellow EM interns or attendings have bad bedside manner, in fact I think we're quite pleasant to patients (I think workign with the uninsured and the drunk etc has had an effect on that).

Q, DO

 

[Goofyone]

Originally posted by Blanch
Dear Abbey,

I bombed my first patient interview for my schools Doctor Patient Relationship class and am feeling pretty lousy about it. You're probably thinking, how on earth could you bomb something like that... I guess I just got really nervous. The guy didn't seem like he really wanted to be interviewed in the first place, so I just didn't feel comfortable asking all kinds of personal questions. One of my questions about the patients feelings towards his illness caused him to break down. This made me even more nervous and lets just say I handled it very poorly... didn't wait long enough before continuing, started going all over the map with my questions, and eventually got "shut out" so to speak. I walked out feeling like I was hit by a freight train. And then the feelings of failure, why am I here, how am I ever going to be a doctor started creeping in. It's really kind of embarassing, not to mention the negative eval that I'm going to have on my file from it.

How can I work on this? Has anyone else had such a lousy first interview? Does it just take a little more practice? Am I doomed to be a pathologist? Thanks for your advice.

So you bombed the "standardized patient interview."

OH, don't worry about it. Those school interviews suck. I think the people doing it have some kind of vendetta against doctors and want to humble us before we get out into practice.

I bombed my first one last year too. Each one after that is a little better. Then this summer I worked with a doctor for a month in a clinic for credit at my school. I did interviews with practically all of the patients. The doc gave me a very good evaluation and one of the patients told him that I was much better than many of the doctors she's seen in the past!

Practice, practice.

BTW, if you go in very prepared and know all the questions you need to ask without thinking too much about it, then you'll not worry too much about questions and you'll be able to relax and just talk to the patient a little. Just don't put too much pressure on yourself. Pretend that you're talking to your grandmother/father-- it works for me.

 

[souljah1]

Practice practice practice. A lot of my classmates who are very good at interviews volunteer at our student run homeless clinics and practice their H&P skills there. Do you have any clinics at your school were 1st and 2nd year students help collect the H&P? That would be a great, low-stress environment for working on aspects of your interviewing style that need improving. I also recommend finding a physician (or physicians) that you feel would be willing to help you and shadow them. I have done this a few times in first year. He would set me up with patients and I would interview them and practice the PE skills that we have learned. I would then do a quick right up (mostly CC, HPI, PMH) and recite it to him. He would critique me and make suggestions for improvement. It really helped to have someone whose style I respected take the time to help me. I know that at the beginning of first year I felt out of place interviewing a patient in front of instructors and classmates. It seemed almost forced. Now when we interview patients while preceptored or in small group - I feel much more comfortable. There are, however, always going to be patients who make H&P's really difficult.

Keep your head up.

 

[jldavis]

First year interviewing is always more difficult than any other year. I don't think I know of any of my classmates who did not inprove by the second year. Hang in there. This experience should be mentally filed away in your folder of mishaps from medical school. There will be more entries in this file. Just wait til 3rd year.

 

[doc05]

please don't lose any sleep over this. it is unimportant to say the least. In ms1/ms2, we of course had similar exercises which were painful for all involved. Doing this just once per week didn't help.

by the end of your first couple weeks of ms3 (perhaps your first day, if you're on a busy service), you'll see tons of patients and it will become easy.

go study anatomy!

 

[Sessamoid]

As many have said, don't sweat it. Most of us have bombed one of our early patient encounters. Even in private practice, there are some patients that really test our patience and personal skills.

Getting to Quinn's anecdote, I think that tactfully redirecting and gracefully exiting an interview with a rambling patient is one of the hardest skills to learn. I've used all sorts of weird redirection techniques, and even weirder exit techniques. I've listened to faint overhead messages or pages in the hospital as if they were for me and excused myself after I had all the information I needed. During medical school and residency, I've had friends page me out of rooms I knew would be prolonged and painful interviews. If none of those above present itself, I'll use the excuse that I need to put in the orders to expedite the workup, with the promise to return later. If the patient is visibly uncomfortable or has expressed some immediate need during the interview, I'll excuse myself to find the nurse to attend to the patient. The possibilities are endless!

 

[sanfilippo]

I agree with what most of the folks here have said. It's your first year, and there will be lots of opportunities to come to hone your skills when dealing with patients...even some residents are that great with rapport...

Also, some of us tend to react differently to "fake" patients. When you know you're dealing with "real" patients with "real" issues, it evokes more of a personal, emotive reaction in you than with the actors. Also, the clinical scenario can also influence how the actors perceive you. If it's a situation with which you have had not much experience, say an ER scenario, then your naivete can show through, as it did with me.

Good luck
-S.

 

[DrQuinn]

Originally posted by Sessamoid
Getting to Quinn's anecdote, I think that tactfully redirecting and gracefully exiting an interview with a rambling patient is one of the hardest skills to learn. I've used all sorts of weird redirection techniques, and even weirder exit techniques. I've listened to faint overhead messages or pages in the hospital as if they were for me and excused myself after I had all the information I needed. During medical school and residency, I've had friends page me out of rooms I knew would be prolonged and painful interviews. If none of those above present itself, I'll use the excuse that I need to put in the orders to expedite the workup, with the promise to return later. If the patient is visibly uncomfortable or has expressed some immediate need during the interview, I'll excuse myself to find the nurse to attend to the patient. The possibilities are endless!

Thankfully, in the ED, we have more options than other specialties. It'd be hard in the middle of a patient's first visit to the PCP as a full H&P is taken to excuse yourself like we can... *sigh* its probably been a while since you had to come down to the ED to take a full H&P! (Got my 1 month of G-Wards out of the way, no more for me).

Q, DO

 

[Sessamoid]

Originally posted by QuinnNSU
Thankfully, in the ED, we have more options than other specialties. It'd be hard in the middle of a patient's first visit to the PCP as a full H&P is taken to excuse yourself like we can... *sigh* its probably been a while since you had to come down to the ED to take a full H&P! (Got my 1 month of G-Wards out of the way, no more for me).

Q, DO

How about, "Excuse me, but I have to take a dump."

 

[DrQuinn]

Originally posted by Sessamoid
How about, "Excuse me, but I have to take a dump."

Actually the chief resident with me on Trauma this month had to excuse himself from a lap appy a few months ago because the sandwhich he had from Subway (have one here at TGH) made him spew like a geyser and spray chocolate water out of his arse. Well, atleast hte patient was under general...

Funny thing is, he still eats the same type of sub now.

Q, DO

 

[ERMudPhud]

Originally posted by QuinnNSU
the sandwhich he had from Subway (have one here at TGH) made him spew like a geyser and spray chocolate water out of his arse.

Q, DO

For real fun try working an overnight ED shift as the only doc in the hospital all while suffering with the same affliction. I still don't know what did it to me but I'm very careful about what I eat before a shift now.

With that note, its very clear that this thread has completely wandered off track

Oh, and in terms of excusing oneself, I generally don't even make excuses any more. I just say excuse me and run off when I have to. When patients see how busy the ED is they seem to understand.

 

[uclacrewdude]

good way to practice:

go into a hospital and just sit down and talk with patients. not really about anything in particular, just talk to them.

 

[imagin916]

Although I am not a doctor, I am a nurse that works in the ED and I would like to add my input about patient communication. I wholeheartedly agree that communicating with patients is the hardest part of patient care. Mastering this takes time and experience. I just wanted to offer you some encouragement. I work side by side with many med students and new residents, and although they are experiencing the same fears that you are, I am observing thier interactions with the patients, and I know that they went a lot better than the student/resident thought it did. You feel down on yourself and that you did a "bad job", but when you walk away from the bedside and I walk over to the patient after you are finished, 9 1/2 times out of 10 the patient will say to me "I like that doctor" or "She/He was very nice". Like some other posters have mentioned, LISTEN to your patients. This is the best way to establish a good rapport with them. Dont act judgemental (I have rarely seen anyone do this, but it happens), and walk over to the patient and speak to them like you know what you are doing, even if you dont feel confident. I notice a big difference in how the patient reacts to the med student/resident when they show that they are confident compared to if they go over to the patient shaking like a leaf. You know your stuff, you just have to make the patient feel like they are in good hands. Plain and simple. Good luck in your studies, I know you will be successful.