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Is Your Patient Telling You Everything?

 

I. Introduction: 

Charting the best treatment for your patient requires a volume of information. Be it something as small as the flu or even more severe such as bronchitis, or an onset of psychological symptoms, you will only be able to plan a course of treatment depending on how completely and honestly a patient describes their symptoms to you.

Doctors are required to be adept in the “art” of interviewing their patient. Being able to judge how a patient will be during their conversation comes from the experiences of hosting different people throughout their careers and practices, and intelligent interviewing methods like open-ended questions or having patients fill out a diagnostic questionnaire are all part of the job. Properly assessing patients before administering anesthesia for surgery, for example, and encouraging them to be honest about it could help prevent a fatality.

Larger hospitals are usually busy with the influx of patients shortening the doctor-patient time slot; in such cases, head nurses or the doctor’s assistants take verbal history of the patients, or receptionists provide patients with written interview inquiries. Some hospitals utilize online forms of symptom reporting, perhaps to encourage more input which would otherwise be difficult to obtain from patients who have trouble communicating directly with their physicians.

II. Patients and Disclosure:

Clinicians understand that a patient’s medical history can provide even more valuable information than laboratory testing or physical examination (Rich, 1987). Verbalizing symptoms helps build rapport within the doctor-patient relationship, and provides more detail to paint a full diagnostic picture, coupled with laboratory tests and the physical examinations. However, be wary of three pitfalls of diagnostic interviewing:

Withholding information:
An online survey consisting of a sample of 3000 Americans revealed that close to 50% of patients withhold information from their doctors and use generalized terms to explain their symptoms. Some of the most common topics in which this occurs include discussion of sexual activity, alcohol/tobacco/drug use, diet and current medication.

Patients do this voluntarily to avoid eliciting a derogatory response from physicians, or involuntarily in some cases. However, such information can explain why the patient’s body is a host to certain ailments.

Half truths:
A patient reporting symptoms of depression may at times skip mentioning suicide ideation or an auditory hallucination. In this case, reporting suicide ideation would allow the psychiatrist to treat the patient for major depressive disorder, and mentioning auditory hallucinations could help the practitioner explore schizophrenic tendencies of their patient.

In cases like these, trust your expertise in human behavior and gauge through tone, word choice and body language if there is more to the information being conveyed. If a patient looks like they want to mention something and then do not, keep listening to them with your body language and eye contact, but remain silent. Oftentimes, this can subconsciously coax them to continue talking and they may release more helpful information.  

Lying:
Lying is defined as the act to mislead another person by distorting truth, fabricating and embellishing the story to avoid punishment (Ekman, 2001; Jordan, 1982), or to preserve autonomy. In a patient’s case, they may lie to you to avoid:

  • Being exposed to family
  • To access controlled medication
  • Obtain disability benefits
  • Or to avoid legal consequences/incarceration

Lying to a physician usually happens via malingering, which is consciously simulating or faking symptoms for self-advantageous purposes.

Unbeknownst to them, in certain situations, you are at the risk of performing the Type I and Type II errors in your diagnosis and evaluation if your patient presents information to you in such ways.

III. The Medical Interview:

As a professional, you should be aware that because your work involves studying your patient and hearing them out, your judgment depends on the information you are presented with. Assuring patients of doctor-patient confidentiality and establishing trust in the first few minutes of the appointment may help them let their guard down.

Revisiting the aims of a medical interview, you must categorize your information into what your patient tells you about their ailment and how they speak about it. A record in chronological order is to be maintained alongside observing your patient for signs of symptoms they have complained about.

The interview skills you are required to practice include asking questions to facilitate conversing about their illness, and to ask open-ended questions while practicing effective listening. In your interview, be sure to sift for the chief complaint and symptom triggers. Giving options to rate pain, or talking about how long the symptoms have persisted, will help you summarize the interview to see the overall picture of the present illness.

Going beyond the patient will also help establish a fuller picture – asking about family history, social history and psychological history can help you organize the diagnosis more effectively. The more information you have at your disposal, the better.

IV. When Patients Conceal Information

Unfortunately, patients do not realize that full disclosure is the best way for us to treat them. Missing one minor detail can make a doctor misdiagnose appendicitis as food poisoning, or vice versa – and the practitioner or physician is not to blame if the treatment proves ineffective or aggravates symptoms.

Be wary of signs. Sigmund Freud commented that human beings are unable to keep secrets and will always express them in one way or another: “He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips; betrayal oozes out of him at every pore.”

First Impressions:
One of the first ways of gauging how talkative your patient may be is to see their willingness to be treated, after which an ideal setting and an amicable attitude should be presented to ease them into the appointment. Note their attitude and countenance – are they hostile, cooperative or agitated?

Also observe their pitch and tone. Those who speak with a higher pitch and offer unnecessary details should be questioned in an intelligent manner to procure more relevant information.

Eye Movement:
A patient who avoids questioning, withholds information, or is lying will find it difficult to maintain eye contact.

Some researchers have also added that physicians should note if their patient’s eyes tend to move towards the dominant hand’s direction often, this may indicate that the patient is fabricating their words and shared information.

Pursed Lips:
Patients with tense or pursed lips display avoidant behavior. This agitated display of behavior signals towards withheld information and anxiety.

Hand Gestures:
Patients who are being forthcoming or honest tend to unconsciously display their palms. Those who are hiding their hands, clenching them or pocketing them are assumed to be concealing information

Comparing and Contrasting:
In psychiatric cases, practitioners can compare and contrast their patient’s information by asking family members to verify certain things they are unclear about – for example, a minor with bipolar disorder will not be able to give a full picture of what is required to understand how he/she is presently doing, in which case, reports from his/her parents or caretakers will be supplementary to the process.

In other cases, a hired nurse or caretaker can also be questioned to get a fuller picture of your patient’s ailment. However, the amendment of ethics comes into play, and breaching doctor-patient confidentiality becomes a risk.

V. Facilitating Disclosure

It is, after all, the physician’s job to encourage their patient to give them full disclosure. To ensure patient satisfaction, physicians and healthcare professionals must demonstrate effective relationship skills (Dordevic, 2012).

R.E.S.P.E.C.T (Randa Zalman):
In 2015, a CSO presented some vital communication skills that medical practitioners can employ to encourage patients to confide more.

R – Rapport: Factors like physical appearance, phrases of comfort, eye contact and being attentive are factors that can ease patients into their appointments with you, paving way for a more comprehensive picture for you to base your diagnosis on.

E – Explain: Asking patients various questions pertaining to their physical and emotional state, and asking them to explain will help them verbalize their concerns better. It will also ease them into the interview even more.

S – Show: Zalman suggests using the 7:1 ratio of compliments to contrastive criticism when speaking to patients. She also reiterates the importance of action over words – showing patients resources and materials which will help their condition is a way to display involvement in their treatment and make them feel safer.

P – Practice:  As a marketing and communications officer, Zalman is big on feedback. Various hospitals have digital rating devices at the reception to see how your appointment went. Physicians should be open to feedback – after all working with patients requires versatile interpersonal skills.

E – Empathy: Doctors and practitioners are pressed on time with short appointment slots, meaning they usually skip to the main complaint and evaluation. Exercising empathy is important to a patient; it makes them feel heard and builds trust.

C – Collaboration: Work with your patients. Explain your methodology and prescriptions, and give as full a picture as possible of medical procedures to make them feel involved in the decision making. This way you and your patient will be able to meet on the same page when it comes to treatment options, which is ultimately beneficial for your professional image and the patient’s health.

T – Technology: Zalman advises to utilize no more than three means of communicating with your patients, as overdoing it can cause anxiety or annoy them. Allowing patients to contact you outside of clinical settings will also encourage them to explain the onset of their symptoms during treatment. Of course, you have to explain professional boundaries to your patients if you pursue this method.

 

Non-Verbal Ways:

Body Language: Doctors and practitioners should be wary of expressing emotions. Maintaining a neutral or concerned facial expression, facing your patient, with hands calmly clasped – these minor components of body language can convey attentiveness to your patients. It’s not easy to express vulnerability in front of an individual who will not look at you.

Appearance: Maintaining a spick and span appearance after mid-afternoon is not easy. However, dressing the part and being well groomed will allow your patient to trust you as a professional who looks the part of his/her designation, which will subconsciously put your patient’s anxiety and reprehension at ease.

Speech:

Word Choice: Using neutral and respectful language with your patient is important. Be sure to notice their language preferences; some may prefer to speak in their mother tongue because their English may not be as strong. Do not use alienating language.

Maintaining an interested and concerned tone with a neutral pitch will also help your patient to ease into your confidence. They have taken a big step to face an intimidating problem, and are not ready to be chagrined for it.

Use simple words and layman terms to explain medical or technical terms to the patient. It enables them to feel in control of their treatment and lets them be more open with you, which ultimately benefits the both of you in charting the treatment plan.

Intervening: Litchstein (1990) observed that the most detailed medical interviews conducted were those where practitioners and physicians exerted as much control as was needed. Allow your patient to talk freely and form their conversation, and give them adequate time to form their answers.

Doctor-Patient Confidentiality:
Remind your patient of your confidentiality oath if they seem insecure – it’s not easy to open up to a stranger, albeit a professional, about weaknesses or complaints. Trust and emotional safety are the first things a patient needs to feel from you to be able to open up.

At times, young or adolescent patients fear involvement of their caretakers in sensitive medical problems because of fear of consequences, which could arise due to cultural, gender or various other social issues that exist. Because of this, various young patients choose to eschew discussing health related concerns openly (Alli, Maharaj, & Vawda, 2013; Harvey at al.,2008).

However, as the health boards and psychiatric boards have regulated, if a patient expresses the desire to harm themselves or another individual, doctor-patient confidentiality can be broken – and patients should be informed about this, too.

VI. Conclusion:

The importance of humanistic engagement in medical interviewing will make or break a patient-practitioner relationship. It all culminates to patients wanting to feel heard and included.

Patients are aware of your expertise and skill, hence they scheduled themselves in, but what they require most is to be heard and informed of their ailment. Practicing empathy-conveying communication will increase amity between the two parties – a receptive doctor will be spoken to candidly, which in turn will elicit an open conversation from a doctor’s end.

It remains on your shoulders to fulfill the Hippocratic Oath – to treat to the best of your ability and preserve privacy of your patient. In order to exercise your expertise, you are required to assure your patient of their rights, and to ensure a complete evaluation before treatment commences. Practitioners should display effective communication in both verbal and non-verbal forms. Use your expertise to read between the lines and discern what your patient is trying to express, and question them to keep them involved in their diagnosis and treatment.

Being a healthcare practitioner is no easy feat – it is a remarkable mission. And because of the prestige awarded with this stature, along comes the responsibility to deliver the best services in the most humane way possible.


 

Resources:

Alli, F., Maharaj, P., & Vawda, M. Y. (2013). Interpersonal relations between health care workers and young clients: Barriers to accessing sexual and reproductive health care. Journal of Community, Health, 38, 150–155

DePaulo BM, Jordan A. Age changes in deceiving and detecting deceit.
In: Feldman RS, ed. Development of Nonverbal Behavioir in Children.
New York, NY; Springer-Verlag; 1982.

Dorđević V, Bras M, Brajković L. Person-centered medical interview. Croat Med J 2012; 53: 310-313.

Ekman P. Telling Lies: Clues To Deciet In The Marketplace, Politics, and Marriage.
New York, NY: WW Norton & Company, 2001.

Harvey, K., Churchill, D., Crawford, P., Brown, B., Mullany, L., Macfarlane, A., & McPherson, A. (2008). Health communication and adolescents: What do their emails tell us? Family Practice, 25, 304–311.

Lichstein PR. The medical interview. In: Walker HK, Hall WD, Hurst JW, eds. Clinical methods: the history, physical, and laboratory examinations. Boston, USA: Anthony C. Berman and Darryl S. Chutka : Physician-patient communication skills 249 Butterworths; 1990. p 29-36

Ricj EC, Crowson TW, Harris IB. The diagnostic value of the medical history: Perceptions of internal medicine physicians.
Arch Intern Med 1987; 147:1957-60.

 

 

 

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