The Art of the Interruption

[acadianvoyager]

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How do you redirect your patients without being a giant d***? What are the phrases you use to harness the "golden moment of interruption?" Examples of WHEN to interrupt include the following....

1. When the patient says, "Let me start at the beginning. I had a rash 5 years ago..."
2. When the family member interrupts with, "Tell her about the rash."
3. When you finish obtaining the HPI and in the ROS the patient says, "Oh, and I have a small rash on the corner of my pinky..."

Obviously, I rarely find rashes helpful.

Now, exactly what do you say? And HOW do you make sure you're not missing crucial information? For example, I interrupted a septic patient whose triage note said "known UTI on abx not working" too frequently and glossed over her productive cough...

 

[MechEDoc]

Sometimes I'll redirect the conversation by listening to the first little bit of their spiel, then asking if I could come back to the that in a moment, but I'd like to ask some background information about their health. I'll then ask everything that I want (more distant information first to make my line seem reasonable), then return what brought them in with a series of focused questions.

 

[deleted547339]

In order of how patient I am:

“What are you hoping I could do for you today”

“Why are you here?”

“Stop talking....”

 

[deleted109597]

"stop talking" is the nuclear option, but I use it on occasion.

 

[Arcan57]

If I need to redirect, I’ll try and ask open ended questions that seem relevant. If that’s not working I wait for them to pause then start firing closed questions until I’ve regained a focus on circumstances that lead to their presentation to the ED. If I have to I’ll start grouping questions together, then picking what roads to go down based on relevance to chief complaint. By circling back to clear up ambiguities, (“any chest pain or vomiting ? Yes.”) I kind of train the patient to provide the history in a way I can process into a useful differential.

 

[Ridge_Runner]

If I need to redirect, I’ll try and ask open ended questions that seem relevant. If that’s not working I wait for them to pause then start firing closed questions until I’ve regained a focus on circumstances that lead to their presentation to the ED. If I have to I’ll start grouping questions together, then picking what roads to go down based on relevance to chief complaint. By circling back to clear up ambiguities, (“any chest pain or vomiting ? Yes.”) I kind of train the patient to provide the history in a way I can process into a useful differential.

This.

 

[deleted547339]

More seriously, when I get a patient who refuses to focus, I will increase my speech cadence and ask pointed questions that can’t be answered with “well, you see, five years ago my second cousin.” Every now and then, you still won’t get a focused answer. When that happens I will tease the same question verbatim - that usually clears it up.

 

[Alvarez13]

Before I see a patient, even in triage, I glance at the chart to get a sense of their history. When they start to tell their story about the 7-year abdominal pain I quickly interject with "yeah I saw the reading of the last CT scan and saw that the even did a colonoscopy". Stops their rambling, they think I know their whole history, and I can ask what's new. We have Epic connected with our outpt clinics and the other local EDs.

 

[GonnaBeADoc2222]

I just interrupt. There's no art about it.

 

[GeneralVeers]

I usually say "It sounds like you have a lot of things going on. Let me ask you a few specific questions so I can understand better why you are here"

 

[thegenius]

I just interrupt. There's no art about it.

Yup.

 

[Angry Birds]

There is an art and here it is:

Always look at the chart first and read nurse's triage notes (unless super critical patient).
Then, do the physical exam first before history.

"Hi, I'm Dr Angry Birds, I saw that you told the nurse you have asthma and came in for shortness of breath. Do you mind leaning forward so I can listen to your lungs?" *Listen to lungs* (this shuts the patient up from an already shut up position.) "I hear some wheezing, have you been using your inhaler?" (super directed question) "You're having an asthma exacerbation, so let me fire up some steroids for you and start some nebs right away." And of course, I will throw in a few more questions, such as ask about fever (yes/no question), cough (yes/no), etc. Just exactly what I need. Then, "Alright, I'll check back on you after you've got the treatments. I'm confident you're gonna feel a lot better. Let us know if you need anything." Then, I peace out.

Underlined words are key. Makes my quickness turn into a positive (which it is in our line of business).

Reversing H&P has been a game-changer for me.

 

[Groove]

I'm very pleasantly blunt and will forcefully redirect them until they give me the information I need. If they can't or are incompetent, then I will further force them into simple "yes" and "no" questions. If family keeps talking, I'll nicely and sternly ask them to stop and tell them that although I'm interested in what they have to say, I want to hear from the pt first. If both the pt and the family is incompetent, then I go to the EMS report (for the ABA patients). If EMS is in the room and the pt starts talking before I've heard the report from EMS, I quickly stop them so I can hear a focused presentation from the paramedics. I think that does two things...it gives me a hopefully decent first responder history with prehospital course to fall back upon if the pt is a horrible historian and goes a long way to build a good relationship with the firefighters and paramedics. They feel important and I want them to feel like their history is valuable because let's face it, sometimes it's all you've got. I'll usually say something like "strong work guys" if they did a particularly good job. Luckily we've got some strong firefighters and paramedics who will even stick around if we are short staffed to help resuscitate a critical patient.