Vrati M. Mehra is a medical student in the class of 2024 at the University of Toronto.
My colleague and I smiled anxiously at each other as the patient jokingly recalled the story of how her friend accidentally lit her curtains on fire while smoking a cigarette.
Our question of whether our patient was a smoker had prompted this thrilling story. The room, however, emanated a quiet restlessness. Our eyes darting regularly to the empty page in our notebooks that outlined the structure of the interview – OPQRST (a mnemonic used to remember the questions we have to ask our patients about the onset of their condition, precipitating factors, quality of the pain, radiating or not, severity and temporal factors), followed by past medical history, social history, and family history.
We had been prepared that this patient may not be the easiest to interview. With limited time on our hands, we relentlessly tried to guide the conversation back to the patient’s medical history.
“Oh wow! That must have been scary! So, we know you and your friends smoke cigarettes. How long have you smoked for?”
There was a long pause.
“Is that you in the picture?!” The patient exclaimed, ignoring my question, as she noticed my colleague’s hospital badge picture.
“Ah yes,” my colleague replied. We were 20 minutes into the interview and all we knew was that she lived alone, didn’t know what brought her to the hospital, was a smoker, and once accidently had her curtains lit on fire.
We knew the importance of gaining our patient’s trust, so we let the photograph be the topic of conversation for the next five minutes. Then, seeing an opportunity during a pause in the conversation, I jumped in with a question about her family history.
At this point any information pertaining to her health would be helpful, I thought to myself and got a reassuring smile from my colleague who was happy at my attempt.
A bit annoyed at being driven away from her topic of choice, the patient reluctantly told us that her kids were supposed to visit her soon and then dived straight into another story.
The ticking clock on the wall reminded us of all the medical history that remained hidden. We still knew very little about why she was in the hospital in the first place.
I decided to not let the hard structure of the words in my notebook direct me anymore. Though we didn’t know exactly what brought the patient here, it was clear she was sick. And unlike the rest of the medical staff, who were often pressed for time, we as students had the luxury to hear her stories, gain insights through them, and even laugh a little.
Her room was small and divided in four by curtains. She spent most hours of the day alone in her bed, cut off from the rest of the world. And here she was, allowing naïve medical students to speak with her and examine her, all so that we could become better doctors in the future.
I attempted to put myself in her shoes and thought: What would I want if I was in her place? What would make my stay in this hospital better? Instantly, the answer came to me: I would want others to treat me like a person, and to understand me by what I decided to tell them without pushing me toward their own agenda.
I whispered to my colleague who was making her own attempts at the questions, “It’s okay. Let’s be patient. Maybe she will pause for us and then we can ask her if we can do a physical exam.”
For the rest of the interview, we talked about everything the patient wanted to. We learned about her kids, her house, the multi-coloured telephone that lay beside her bed at home where her loyal friends called every day. We learned that she enjoyed playing board games with the same friends and was fiercely competitive.
The pleasant outcome of this method was that it allowed us to participate in the conversation with genuine interest. As we spoke with her, we also conducted a physical exam. We waited patiently to hear her heartbeat or the sounds of her breath when there was a natural break in her talking. Then, we focused on her concerns and how we could help her. She pointed us to the bedsores she had developed which were now also invading her groin where her incontinence briefs gripped her skin.
I looked at the oozing wound and back to her smiling face. She was happily chatting away with us after telling us about her sores and how they were missed when she was given a shower the day before. As I made a note to inform her nurse after our interview, I felt a deep ache in my stomach. Her vulnerability juxtaposed with her powerful personality gave me chills. I was glad that we had let her drive the conversation. Maybe, just maybe, our presence and the lightness of our conversation was what she needed.
We were later informed by our preceptor that the patient had major neurocognitive disorder. We were surprised. Despite spending 40 minutes with her, we had no idea of her diagnosis. Reflecting back, I wonder if our inexperience prevented us from recognizing her cognitive deficits, or maybe it gifted us the open mind required to look past her medical condition.
Nonetheless, this incident taught me the benefit of challenging our assumptions and being creative when interviewing patients. It taught me to allow them the freedom to be authentic, instead of settling for a quick but fragmented image that is constructed by the hard structure of the medical interview. I hope that as I learn and hone the skill of taking an efficient, comprehensive history, I never forget the value of adapting to the patient rather than pressuring them to adapt to our structure.
Acknowledgement: I would like to thank Dr. Lindsay Herzog and Dr. Kevin Venus for their encouragement and support in the write-up of this reflection.
Editor’s Note: This piece is fictional, albeit informed by a real clinical encounter. No real patient details are provided.
Very well written and I applaud you for your courage in sharing this piece. It shows your empathy and that is something no medical faculty can teach you.
Going to have to disagree… unfortunately the experience of the writer is showing here that they are a junior level trainee.
There’s a reason that you should adhere and learn “checklists” is that you need more experience before adding on nuances. You need to know the rules before breaking them and understand when and why you would break them.
Any attending physician and resident would not be able to spend that much time on a patient while not getting to the crux of the chief complaint.
I agree that more nuance and flexibility is important in history taking, but this particular situation was a poor defence of that claim.
Content is really informative.
Thank you for this insightful reflection, Vrati. This was sent to me by a supervisor; it’s definitely an interesting challenge trying to break out of the guiding structure that we spent so much trying to learn and solidify.
Also very grateful for the flexibility we have as learners 🙂