A learner explains a diagnosis to an SP.
[Girolamo Mercuriali via wikimedia]

When learners try to give me a diagnosis, I often feel unsatisfied because the explanation is missing one or more key components that will help my understanding.

When I go to the doctor I want to know these things in this order:

• How has this conclusion been reached? Without a summary of findings or history, I have less ability to relate the diagnosis to my chief complaint. Transparency allows me to trust the diagnosis when it comes.

• What is it? The diagnosis should include the medical term and the layman term if there is one. For instance, if the diagnosis is "Non-Hodgkins Disease" or a "lymphoma," I may not understand the learner is telling me I have cancer. If it is a serious diagnosis, I ask learners to leave a beat at this point so I have a chance to process it before continuing with the other parts.

• What does the patient know about it? After the diagnosis has been named and I know how the doctor has reached that conclusion, it is very effective if the student-doctor opens up the conversation with, "What do you know about [X]?" This allows the patient to lead the conversation and it gives the opportunity for the student-doctor to clear up any misunderstandings or praise the patient for their knowledge.

• How serious is it? Regardless of the diagnosis, there is always a range of outcomes and consequences. I will likely leap to the worst-case scenario unless I know what the range is. My perception may also change based on any previous experiences I've had (directly or indirectly) with the diagnosis. If I'm not going to die immediately, hearing, "X% of people with this diagnosis have Y happen to them" is really helpful. This is especially true if I am hearing the results of a screening test as opposed to a true diagnosis. 

• How long will this affect me? Knowing whether the diagnosis will affect me for three days or three years shapes my ability to understand the scope and impact of the diagnosis. Sometimes learners tell me they will "treat" my condition for a period of time: when I hear this, as a patient I think they mean they will cure it. So I want learners to be clear whether this is a treatment meant to prolong my life, or whether my condition is something that will resolve after treatment.

• What's the next step? And equally importantly, what's my next step? Even if my next step is "wait until the test results come back in 2-3 days," I still know what to do.

Plain language, reassurance, validation, empathy, teach back, collaboration, etc. are good tools to use within this framework, too, but they can't be used to replace one of these steps.

For example:

"Based on your coughing & fever, and those sounds I heard in your lungs, I think you probably have pneumonia, which is a lung infection that causes fluid to build up in your lungs. You're young and healthy so I'm not too concerned right now, but I'm glad you came in so we can treat it before it gets worse. Fortunately, it will probably get better in a couple of weeks after we begin treatment. I'm going to recommend a chest X-ray and a test of what you're coughing up so we know for sure it's pneumonia and so we know what kinds of medications to give you. How does that sound?"

Learners are of course welcome to elaborate on these points if the patient indicates they want more information or clarity. Otherwise, each of these steps should be no more than 1-2 sentences each.

When learners cry

"When doves cry..."
[L'enfant à la colombe via wikimedia]

Only a handful of students have cried while working with me, but they have all been memorable. But I don't take it personally, because they always happen during high-stress scenarios, like when the event is required to pass or when my character has been terrifying. Sometimes the learner is suffering from something happening in their life which magnifies any bump in our encounter into an insurmountable challenge.

Usually these encounters are unsatisfying, but the learner generally holds it together during the scenario. When feedback begins, though, so do the tears. In those situations, I've learned that feedback about the encounter in those cases is almost entirely wasted. What is more helpful is to explore what triggered the student and what's going on for them. Empathy first works for learners, too! If there's time, I may also give feedback about compartmentalization, stress management and how to manage negative thoughts.

In general, feedback should role model the kind of interaction you want with providers. So if I stay with my traditional feedback agenda in those cases, I am training learners to stick to their agendas despite the emotional and nonverbal cues a patient is exhibiting.

New inspirations

Calliope, the muse of epic poetry, approves this post.
[La Muse Calliope via wikimedia]

This post original began as simply a grateful reference to Empathy 101 (how to sound like you give a damn), because I give similar feedback to learners. I nodded deeply in agreement when I read:

• "Reassurance often fails if the physician does not also communicate an awareness of the patient’s deepest fears or concerns." 
• "This model of doctor-patient communication begins with empathic listening and responding, requires reflectivity and self-understanding, and is in itself a healing act."
• The list of "Statements That Facilitate Empathy," which is a particularly useful tool.

But then I realized these quotes and tools are all by the same person, which is how I discovered Dr. Jack Coulehan. Coulehan has written both "Let Me See If I Have This Right… – Words That Help Build Empathy" for the Annals of  Internal Medicine as well as the textbook Metaphor and Medicine: Narrative In Clinical Practice.

Sadly, neither of those references appear to be available via my normal channels, but some of his other books are, and that's how I learned Coulehan is both a doctor and a poet!

For instance, in addition to his own poetry, Coulehan edited Chekhov's Doctors: A Collection of Chekohov's Medical Tales as part of the Literature and Medicine series. Perfect for actors, eh? The Kindle edition has a much more interesting description of it: "In his brief but distinguished life, Anton Chekhov was a doctor, a documentary essayist, an admired dramatist, and a humanitarian. He remains a nineteenth-century Russian literary giant whose prose continues to offer moral insight and to resonate with readers across the world. Chekhov experienced no conflict between art and science or art and medicine. He believed that knowledge of one complemented the other. Chekhov brought medical knowledge and sensitivity to his creative writing—he had an intimate knowledge of the world of medicine and the skills of doctoring, and he utilized this information in his approach to his characters. His sensibility as a medical insider gave special poignancy to his physician characters. The doctors in his engaging tales demonstrate a wide spectrum of behavior, personality, and character. At their best, they demonstrate courage, altruism, and tenderness, qualities that lie at the heart of good medical practice. At their worst, they display insensitivity and incompetency. The stories in Chekhov's Doctors are powerful portraits of doctors in their everyday lives, struggling with their own personal problems as well as trying to serve their patients. The fifth volume in the acclaimed Literature and Medicine Series, Chekhov's Doctors will serve as a rich text for professional health care educators as well as for general readers."

The intersection of art & science is one of my very favorite things. Looking forward to reading more work by Jack Coulehan.

Quote of the Day

[Engraved portrait of Oliver Wendell Holmes via wikimedia]

"The physician's task is to cure rarely; 
relieve sometimes; and to comfort always."

Oliver Wendell Holmes

After 150 years, medical school is still working on this. It makes me imagine what a medical school curriculum would look like if this was its guiding principle.

You're going to be OK

A student-doctor reassures an SP.
[Hope in a Prison of Despair via wikimedia]

When a learner attempts to reassure me during an encounter by saying, "You're going to be OK," I smile on the inside even though I still look worried on the outside. Because I know the urge to comfort a concerned patient is almost overwhelming, and I can't fault them for the impulse.

But it's impossible to guarantee a patient will be OK. If I believe it and it turns out to be wrong, I am going to feel betrayed by and mistrustful of the person who said it. During feedback with learners, most wished they could take back that statement as soon as they said it. But they didn't know what to say instead. So here's the structure I recommend:

• Validate the emotion: sincerely acknowledging an emotion almost always de-escalates it. It makes me feel heard and like the student-doctor is attentive to my non-verbal communication.

• Next steps: of course, defusing the emotion is only the first step. Without further steps, the de-escalation will act as a pause button, but then my anxiety will continue to rise until I know what the student-doctor plans to do about it. The plans don't have to be in great detail, but anything student-doctors are able to do to manage my expectations will cause me to feel more confident in their abilities and less distressed.

• Reassurance: this is generally what "You're going to be OK" is meant to do, but it's hard for it to seem sincere on its own, which is why the other elements help to support it. An expression that indicates care and responsiveness is all that's needed here.

Here's an example of how this could work even in a first-year encounter:

SP: Am I having a heart attack?! 

Student-doctor: I can see why you'd be concerned about that. I'm going to do a heart exam and then check in with my supervisor so we can take care of you as quickly as possible.

Discussion question:
What other reassuring statements could the student-doctor make using this format?

Strength testing

"All right, now push against my hand."
[Werdende Kraft via wikimedia]

When learners do strength testing on my extremities, I often find myself confused by their instructions. Because learners often practice with each other, it means they practice with people who anticipate and act on what the learner intends, not what the learner has actually said. Plus, strength testing involves body positioning in a way where students are less likely to be mindful of physical autonomy.

I wrote about this a bit in "Neuro exam checklist," but it comes up frequently enough that I wanted to break it out into its own post. So this is the kind of feedback I give learners doing strength testing.

This is a living list. Last updated November 3, 2015

• Explain: Why are we doing strength testing, anyway? As a patient, it can look like a lot of work with no clear purpose, especially if the movements seem unrelated to my chief complaint.

• Stop talking: Learners frequently begin the test before they even finish telling me the instructions. So the test could be over before I even understand it has begun.

• Offer simple, clear instructions: I feel strongly that "Push against me" and "Pull against me" are far easier instructions for me to follow than "Resist my force." Or worse: "I'm going to push against you; don't let me." Framing things in the negative (ala "resist me") places a higher cognitive burden on me to figure out what the learner wants me to do to "resist." Plus, telling me to push/pull also makes it clear when the testing has begun, because I am in charge of the movement. If the learner is already pushing against me but I have not yet understood my counter move, it can give the learner a false positive.

• Let me move myself: During strength testing, learners may move my limbs into position while explaining the test, which makes me feel vulnerable. If learners allow me to move my arms or feet into position myself (including during reflex testing), I feel like I have some control over my own body.

• Indicate the end of the test: This can be as easy as saying "ok" or "thank you" (how polite!). Saying "great" or another filler can be awkward if I am clearly not doing well.

• Ease up on exit: When learners are eager to move on to the next test, they may let go while I am still exerting force, which drops my limb rapidly. When this tests neck muscles, this can be especially dangerous. But when learners are careful to ease pressure at the end of the test, I feel much more confident in their ability to be self-aware and treat me with respect.

Teach back

Doves & cherubim are not strictly required for successful teach back.
[L'Annonciation de 1644 via wikimedia]

I love the "teach back" technique. Teach back is a way to verify shared understanding by asking someone to explain their understanding of the instructions and/or event.

Done well, this can keep patients from skating out the door just by smiling and nodding at the provider, even though they didn't understand anything the provider said. When I am asked to do teach back, I find it often prompts me to ask questions I didn't have when asked "do you have any questions?" I might realize I zoned out during the encounter. It forces me to pay closer attention. It also lets the provider know if I've truly understood key details, like how many times to take a medicine per day, what the next step in my diagnosis is, or what will keep the rash from returning.

However, the two most common way most learners employ teach back is  at the end of the encounter:

1. "I just want to make sure you understand everything correctly, so will you please tell me what I've just told you?" 

2. "So, sometimes I am unclear and use big words when I am talking to patients. To make sure I was clear, will you please tell me what you understand of our conversation today?"

Both of these framings are incredibly awkward. As one student told me in feedback, "It's like I have to choose between calling the patient stupid or calling myself incompetent."

So here's the best way I know how to use teach back with patients:

• Start with a summary of the history and physical exam findings. Summaries are awesome in general because they give both the learner and me a last chance to verify/update inaccurate information. But a summary also primes me for teach back because it helps me focus on the things the learner finds important, making it more likely I will recall and retain that information.

• "What questions do you have?" after the summary helps make sure that all questions are resolved before moving to teach back. No new info should be introduced during teach back. Resummarize after all questions have been answered if possible.

• Identify the patient's most relevant support network. Sometimes that information has already been obtained through the social history, but if not, questions like "Who brought you in today?" or "Who are you going to call when you get home?" or "Are you going to need to contact work?" et cetera can be helpful. The student-doctor can ask more than one question to help identify the person I am most likely to discuss my condition with. These questions should be approached with a transitionary tone rather than come across as a complete non-sequiter.

• Now do teach back! "What are you going to tell [person identified in Step 3] about [the next step/your medicines/what we talked about today]? The learner can continue to prompt me in this way about any of the key details they want to ensure I understand. 

For example:

Student-doctor: So let me sum up: You’ve had a rash for a week, and when I looked at your leg I saw circular black dots. So I'm going to prescribe some cream you'll use twice a day. How does all that sound to you? 

SP: Yeah, great. 

Student-doctor: OK. What questions do you have? 

SP: I can't think of any. 

Student-doctor: OK, then we're good. So who brought you into the clinic today? 

SP: My husband. 

Student-doctor: Great, so on the way home, what are you going to tell him about your condition?

There can be lots of nuance here depending on how the patient answers. But this basic structure makes me feel as if the learner is preparing me for a conversation I'm going to have rather than giving me a pop quiz. And because the learner seems like s/he is interested in my life and support network, it enhances our rapport.

Discussion question:

Does your school practice the teach back method? I'd love to see more examples of how to introduce teach back well, or other resources that talk about the concept. Everything I've found doesn't explain it as well as I'd like, hence the generic Wikipedia link.