August 2003 Bulletin

Approaching new orthopaedic patients

Enhanced communications lead to better outcomes

By John R. Tongue, MD

The following bare bones outline contains helpful communication techniques for interviewing new patients. You can use this outline as a quick reference. Post it on staff bulletin boards, locker rooms, conference room walls and on your personal Internet Web sites:

The greeting

Clear your thoughts and smile before entering the exam room.

Wear professional attire, knock and enter at a deliberate pace, not rushed. The patient will size you up in the next five seconds.

Welcoming statement

"Good morning/afternoon/evening!" Smiling, calm, pleasant, consistent voice tone, focused attention.

"Mr./Ms____?" Check pronunciation, patient may prefer you call him/her by their first name.

"I'm Doctor_____." Introductions are especially important in the emergency department.

"Welcome." or "Good to see you." Combine handshake with eye contact.

Sit down; lean toward the patient, two to three feet away while facing the patient.

While the patient is still looking you over, try a simple comment: "How were the roads this afternoon?"-or- "How do you like this hot weather?"

Pitfalls

"How are you today?" In the U.S., this is a greeting–not a question, which can put the patient in the awkward position of responding, "fine," just before being asked to tell you his/her problem(s).

The patient's story

"How can I help you today?" Six simple, empowering words.

Open-ended questions allow the patient the opportunity to define the conversation. Wait until the patient finishes speaking. This is hard to do. Listen carefully. Absorb information without trying to immediately organize it.

It takes most patients two minutes to tell their story. Most doctors interrupt their patient within 23 seconds.

Many patients expect to be interrupted or have little time to tell their story. They may simply respond to your open-ended questions by answering with a single sentence and stop. For example, a patient might say, "I'm here because my right shoulder hurts".

Try responding, "Fine. Tell me all about it!" Usually the patient will now tell their story.

Listen to the patient's key phrases/words. You will often be able to repeat them later to demonstrate understanding and caring.

Facilitate the telling of the story with nodding, facial expression and voice inflections, or repeating a key phrase.

Pitfalls

"What seems to be the problem today?" Patients sometimes react defensively to this question. ‘That's what you're supposed to tell me,' may be what they are thinking.

"Tell me about your shoulder pain." Open-ended, but might give the impression that you are only interested in a body part. This might delay discussion of secondary concerns.

Question the patient's story–not the first impressions of the differential diagnosis.

Be as curious about the person as you are about their medical problem. Try, "Tell me more about…" -or-

"That must have been…(very painful/frightening/frustrating) "

Avoid interrupting with how/what/when/where questions at this time, resisting the urge to jump into a fix-it mode.

Name their expressed or nonverbal emotion. Acknowledging the patient's emotions and values helps them see you as someone who values them as an individual–not the sore shoulder in room three.

Failure to acknowledge the patient's emotion will usually cause the interview to take more time, not less.

Negotiate an agenda

Most orthopedic patients have two or more musculoskeletal complaints they want to discuss. Get them out on the table early in order to prioritize the available time for this visit.

Reflect on your understanding of the patient's story by summarizing what you have heard.

Limit the scope of this day's evaluation if necessary. Offer to reschedule time for complete consideration of secondary complaints.

Orienting statements show consideration and respect. For example: "After your X-rays are completed, I'll be back to review them with you."

Educate

Explain your thoughts with clear, direct words that suit the patient's style.

Use analogies and simple drawings to give the patient perspective and reduce the chance misunderstandings.

Patients forget 50 percent of what you said after leaving your office. Family members in attendance can be very helpful and patient information brochures are often effective. Write the patient's name on the cover.

Briefly disclose something from your life, if it will help the patient relate.

Humor is important, but it can cause misunderstandings. Use it cautiously.

Interact with the patient during any discussion to check understanding. Try: "Is there anything else you've been wondering about?"

After completing the physical exam, ask the patient to communicate to you what they've learned about their musculoskeletal problem and the options you've presented for the patient.

Pitfalls

"Do you have any questions?" Sometimes, this is said with a hurried glance, a low ‘I sure hope not' tone of voice, even with a physician's head nodding ‘no.'

Instead, ask, "What questions do you have?"

Enlist the patient as a partner

Always ask, "How does this fit in with what you've been thinking?" This one question can prevent more misunderstandings than all others. The patient may still have a very different agenda than you realize or may have a deep concern he/she has been holding back. Patients come with a self-diagnosis.

Simplify the treatment discussion in steps.

The closing

After reviewing the diagnosis, treatment and prognosis, say "good-bye" and express hope with a sincere, uplifting voice tone, shaking hands while maintaining eye contact.

Lastly, your unhurried departure confirms the respect you have demonstrated during the medical interview.

John R. Tongue, MD, is chair of the AAOS Communications Skills Mentors Project Team and a faculty member of the Bayer Institute of Healthcare Communication. He is also past chair of the Board of Councilors. He can be reached at (503) 692-5483 or jtongue.md@verizon.net.


Home Previous Page