In this episode I talk about how to conclude the doctor-patient interaction so that both the clinician and patient are clear about what needs to happen. This is the one step many clinicians miss and could do better. A vital lesson from an ER physician whose language resulted in a tragic outcome.
(This is the core of the transcript from the podcast. The Intro has been removed and some areas improved for reading ease.)
In the past 2 podcasts, I talked about the introduction and middle of a doctor-patient interaction. We discussed how to get things moving in the doctor patient journey and then establishing where the journey goes. But the conclusion is where we make sure we all end up where we wanted to go. This is where we clarify final expectations and satisfy any questions.
I have to confess, the conclusion is one of the things I tend to forget. I know many others doctors forget this part too. This happens for so many reasons, in my opinion; the primary one being that the clinician feels that the most important part of the visit is to “solve the problem”.
After a patient leaves, a doctor can sometimes wonder “Did I tell them to do XYZ?"
More often than not, doctors really try to maximize every minute in their work day, since they have a lot on their plate. Sometimes we also think that we offered that the patient got the core information so we feel we can move on to the next patient, the next phone call, or to simply document that particular encounter. But in terms of making a better connection with the patient and to also to prevent any personal anxieties or to clarify in your mind what just happened it’s important to summarize the whole discussion clearly too; so that that you are crystal clear about what just happened.
I don’t know about you, but have you ever walked away or later thought, “Did I tell them to do XYZ?… Did I order that test?” As a result, we end up second guessing ourselves or remembering things later.
Fast is slow and slow is fast. (An important motto to live by).
I know I’ve had to call a patient back to review something with them or ask one of nurses to call them back to do something or tell them something I missed. Sometimes trying to save time adds time later, not to mention stress. One of my mentors in medical school, Dr. Talbot said in his opening welcoming speech when I entered medical school at the University of Alberta, “Fast is slow, and slow is fast”. Meaning, that sometimes trying to be efficient is inefficient. More often than not, taking an extra few seconds saves us so much more time in the long run and gets rid of anxieties and unnecessary work.
So the simple phrase I use with the patient, once I think I’ve gathered all the information from them, is:
“I just want to make sure that I understand things correctly and please correct me if I’ve left anything important out…” and then I summarize what I think I’ve heard.
“I just want to make sure that I understand things correctly and please correct me if I’ve left anything important out…”
Here is an example of something I might say to a patient:
“You had a cough which started 10 days ago, then it became productive 4 days ago, and in the last 2 days, you’ve developed a fever and your cough has been getting worse, but you haven’t had any nausea, vomiting, or diarrhea. Is that correct?”
Summarizing the history lets them know that you’ve heard them correctly and it also creates clarity in your own mind, which is beneficial when you write or dictate your clinical note. This particularly applies when the clinical story is complicated and you need to clarify details it in your mind better. It also gives them time to say things like:
“Actually, I’ve had a severe crushing chest pain which started last night and I’m having difficulty breathing. Did I mention I was on a 14 hour flight from overseas two days ago?”
On occasion, additional information can come up at the end of a conversation, and if you’ve been a clinician long enough, you’ve more than likely heard comments like these yourself. These can change the way you think about what they might be inflicted with. Statements like the one above are not intentionally left out by patients because they are trying to be difficult, but rather they’ve had more time to think about their clinical scenario. Plus, when you are reflecting the clinical picture back to them, it lets them hear it from a different perspective and often in a clearer, more concise manner.
Summarizing the history lets them know that you’ve heard them correctly and it also creates clarity in your own mind, which is beneficial when you write or dictate your clinical note.
We develop a ‘mini-conclusion’ early during the interview with the patient or when gathering a medical history. During this step, it is also useful to clarify what the patient’s expectations are as well. It’s been the case that I’m going through to their whole history and doing the physical and asking them questions about their illness, but all they wanted was a doctor’s note. They have recovered completely and didn’t need anything else, but their employer needs a note so they can return to work. So often in the beginning of the interview I ask the open-ended question;
“So what brings you in today?”
This one question is extremely helpful and is the number one question I ask if there is not a clear reason as to why they came in.
What do you do if the patient says, “I have five other things in addition to the last four things we talked about?”
So, the big final conclusion, after you’ve done the history and physical, is to summarize your assessment and what is going to happen next: whether you recommend medication further investigations, etc. It’s also useful to ask them if there any other questions or concerns that they may have:
“Do you feel that we’ve covered everything we need to today?”
This is important for three reasons;
Firstly, it shows you are genuinely interested in everything they have to say.
Secondly, you are clear about the next steps of the plan you’ve created together. This in turn makes better connection with the patient. Incidentally, this is also the time when people bring up their hidden concerns that they may have been too shy or worried to talk about initially. For instance, they may have been worried about a potential cancer because of the symptoms or lesion they had. That question “Do you feel that we’ve covered everything we need to today?” opens up the clinical conversation door further so that they can say what’s on their mind. You essentially have given them permission to share again.
Thirdly, the reason for having a clear conclusion, and a proper framework of an introduction, middle and conclusion, is that you can feel satisfied that you have covered as much as you possibly could. It’s not always possible to please everyone, but you have created a process that is clear and correct. Therefore, you can go home and sleep better at night because you are following a well-organized framework in a patient interaction, especially in your busy day.
Here is an important hurdle we have all come across:
What do you do if the patient says, “I have five other things in addition to the last four things we talked about?”
It’s important to remember that the ER doctor was not a bad doctor, or had ill intent for that family. This story is one I tell all my medical students and residents.
So barring any medical emergencies such as crushing chest pain, severe depression, suicidal or homicidal ideations, I’ll say “Unfortunately I can’t deal with all those issues today because we haven’t scheduled enough time to discuss all your concerns. Why don’t we reschedule for more time in the near future?”
One additional point I would like to address is how to discharge a patient.
Discharge Instructions:
Giving proper discharge instructions may seem simple enough to do, but often what we think sounds right, or clear in our mind, is not necessarily what is heard by the recipient; especially if there is a language barrier, hearing difficulty or if they are cognitively challenged.
Here’s a true story I heard from a CMPA (the Canadian Medical Protective Association) educational session. Note, this happened to an exceptionally good ER doctor who was working in a Pediatric hospital.
The situation was that a couple brought in their little toddler/baby into the ER because the child had been having vomiting and diarrhea for a few days. The doctor appropriately assessed the child, initiated some treatment for mild dehydration, and gave the parents some advice on how to keep the child hydrated. He then said something to this effect:
“If nothing changes, then bring your child back for reassessment.”
The child continued to have vomiting and diarrhea, so as far as the parents were concerned, NOTHING HAD CHANGED. So, they did not bring the child back for reevaluation. In their mind, they felt nothing changed, but I’m sure the doctor meant “If the child doesn’t change for the better, bring the child back.” Unfortunately, the child died from dehydration.
The ER doctor was found negligent for not giving proper discharge instructions. It’s important to remember that the ER doctor was not a bad doctor, or had ill intent for that family. He, for the most part, was excellent at his job, but unfortunately we hear about these cases because it’s so tragic. He had saved so many children’s lives, but it’s the one case that he may have thought he handled well, but didn’t give clear discharge instructions and unfortunately it ended in tragedy.
Write some discharge instructions down for them, especially parents, and elderly patients who may forget.
I always tell the medical residents and students this story because it illustrates the importance of being clear and mindful about the language that you are using. In hindsight, a better way to have given discharge instructions, in the above case, would go along the lines of:
“If your child continues to have vomiting, diarrhea or a fever, or is not peeing, you should bring him back in the next 12-24 hrs, or if you notice any new symptoms. If you are worried, please don’t hesitate to bring the child back for a reassessment. He looks fine now, and he should start to get better in 24 hrs.”
We, as clinicians, know the dose of acetaminophen or ibuprofen, because we’ve done it for many years, but for a parent, this may be the very first time they have ever been told the correct dose
If there is something extremely valuable I’ve learned over the years in medicine, that is, an individual can be fine when you first see them, but things can change quickly and unexpectedly. I’d rather be exceptionally clear than not clear about what they need to know.
I also add in the phrase “I’m telling you this as part of good discharge instructions and education in case you didn’t know. I’m not trying to scare you but I want to be clear about possible outcomes”.
A final tip is that I will write some discharge instructions down for them, especially parents, and elderly patients who may forget. When patients come in to see you, they are not often well, as they are worried about so many aspects of their health and situation. We, as clinicians, know the dose of acetaminophen or ibuprofen, because we’ve done it for many years, but for a parent, this may be the very first time they have ever been told the correct dose.
In summary, having a proper conclusion helps not only the patient, but also helps the clinician in many ways. Here are the key points from this episode:
1. Summarize the visit as you understand it and ask the patient if there is anything else they would like to add.
2. If you can’t address all their issues in one appointment, don’t be afraid to ask to reschedule the visit depending on the appropriateness of the issue. Obviously patient safety should always be a key priority.
3. Clarify what they are expecting from the clinical visit.
4. Give proper discharge instructions in language that they can clearly understand. Keep it simple and don’t use medical or fancy words; when people are not well they don’t hear everything clearly.
5. Write down any instructions for them, it only takes a few seconds. Remember “Fast is Slow, and Slow is Fast.”
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I'm Dr. Lalit Chawla and thank you so much for listening. Let's together make a greater more effective community and inspire people to live with Greater Harmony, Joy and Magic in their lives.
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Lalit Chawla
(A special thanks to the talented William Brown who edited the above transcript)