Fumbling with the Tools of the Trade: Empathetic Statements

"... So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds..."

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I sometimes feel a little awkward using my new set of tools of the trade.

I'm not talking about the otoscope, or the opthalmascope, or the stethoscope, or the rectoscope (I can't wait!), or the tongue blade (apparently the technical term for 'tongue depressor'; the public caught on and started using the medical term 'tongue depressor,' so 'they' had to change the medical term to something more scientific and dangerous sounding. "Tongue blade should suffice," said the men in the white coats in the dimly-lit strategic medical equipment naming room.) Yeah, I'm all thumbs with all those tools still (as is my classmate who inflicted great pain on me whilst using one of the above scopes in a Clinical Skills learning session), but those aren't exactly the tools I'm referring to.

The 'tools' I'm referring to are the tools we learned during Communications Skills class, or "We Have A Past History Of Taking Crap for Our Graduates Being Socially Awkward And Insensitive To Patients So We Will Mandate That All Of Our Medical Students Take This Class On How To Talk To Patients Without a) Them Thinking The Doctor Hates Them, b) Them Thinking That They Will Sue The Doctor, Or Worse Still, c) That They Should Stop Donating Money To The Medical School From Which The Doctor Graduated." (That's the course title. Look it up.)

These 'Tools' are the Sit Down, the Get Consent or Die a Painful Immediate Death, and the most difficult to master secret ancient ninja maneuver, the Empathetic Statement.

The first two are pretty easy. "Sit down to create the impression of spending more time with the patient," we were told. Funny, I figured I'd just create that impression by spending more time with my patients. Shows how much I know. Moving on.

The second tool, Get Consent or Die a Painful Immediate Death, is pretty self explanatory and consists of making sure that the patient is willing to be interviewed by me. I have to get permission to talk to the people and I still don't even examine them on my own yet. Even if I screw this one up, my Medical School has covered their legal bases by layering - the patients are told when they book their appointment that medical students will be there, there is a "This Doctor is Teaching Medical Students" slash "Go Easy on the Medical Students, We Can't Have Them Quit On Us This Far In" certificate in the waiting room, the doctor asks them if it's OK to be questioned by a rookie, and finally I, the Medical Student of whom the patients have heard so much and are by now wondering why they have to be so sure they want to talk to me, ask them if it's OK.

(On a bit of a side note, in case there aren't enough side notes already, there are patients who decline to have their appointment on Wednesday afternoon once they find out that there are medical students in the office then. I'm collecting names so that I can decline to treat them or their children in the future. Just kidding, there are still some things that I don't mind putting off seeing in real patients until I've had a chance to be trained with standardized patients. You may recall what I'm referring to.)

Back to the tools. While the first two could be mastered by any layman, the final one, the Empathetic Statement, has pretty much become one of those things that haunts you even when you've punched your clock and have left work. It's awkward to wield, and takes a while to master, and at times you just close your eyes and hope it's working and you're not just embarrassing yourself, but when it is effective, man is it a deadly blow. It's kindof a secret weapon of new doctors, too, so don't tell anyone I told you this, we're sworn to confidentiality (which is why I'm sworn to anonymity)... I'll tell you, but I just don't want you, in your next doctor's appointment, to start wondering if a doctor is genuinely nice, or they have had to receive training on being nice to patients and are whipping out a full blown Empathetic Statement assault on you. Assume the former.

So I pulled out this empathy comment in front of a patient at my Family Practice class on Wednesday. I figured I hadn't used one in a while so I should get some more experience. I tried hard to mean it but I guess I didn't really, and so soon after I started saying it I began hoping the patient wouldn't catch me. I was interviewing this patient about her painful urination, now on my list of afflictions that I hope to treat rarely and acquire never, and I then chose to pull out an Empathetic Statement. It was slightly misplaced, and a little bit out of context. I felt really phony and I hated myself for it for a brief few seconds. If she wasn't so busy trying to make sense of my questions while I asked her to describe her pain in terms of its location, intensity, nature, character, mood, demeanor and favourite food and color, she might have noticed that my Empathetic Statement, "That must've been difficult," isn't exactly the most ideal interviewer response to "But the pain got better when I drank cranberry juice."

Okay, it wasn't actually that bad. I think what actually happened was that she told me that the pain was worse than ever before and I said that it must have been difficult. But I still felt phony saying it. This is what I'm talking about when I say that work stays with you even after you punch out. You see, it's rough when I do say something like "That must've been really frustrating!" spontaneously, even in normal conversations, because I feel like people - especially if the conversation is with someone in my class - they think I'm just pulling that out of my ass(ignment book for Communications Skills class). We joke around enough with FIFE (ie. Classmate approaches me and tells me they locked their keys in their car; I respond, "Awwww, how is this affecting your functioning? What are your fears?") so it's logical for them to think that I'm pulling out an Empathetic Statement because we were taught to, and not because I actually mean it.

Fortunately it doesn't usually go that bad. I have never actually gotten in trouble or accused of brash falsehood when I have used an empathetic statement, genuine or not. But I still hope this will stop being so awkward soon, and that when I actually do mean the statement, or even on those rare times that I don't and am just trying hard to be a bit more human, that my efforts will be appreciated nonetheless.

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Learning by repetition, repetition, and repetition

A comment left on my blog on an earlier post reassured me when I wasn't sure if P = MD was such a good idea. My good friend and mentor "Anonymous" wrote, "a 60% average in non-clinical years will still set you up to be a very competent physician-in-training during your clinical years."

This came to mind again in our Family Practice class today. We were taught in lecture how to write notes in patient charts using SOAP (Subjective, Objective, Assessment, Plan) and how to FIFE our patients...

...for perhaps the fourth time.

Clearly, Mr. Anonymous was correct in telling me something that I now know well about med school: They won't let us out of here not knowing the important stuff.

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"Don't Ask Shit Questions": To FIFE or not to FIFE

Another med school first.

I'm about to tell you about the first time that I was sworn at by a patient.

I've heard patients swearing at doctors before, but never at me. This was a wholly new and wonderful experience and I am taking it as though I have reached new depth in my irreversible spiral of being sucked into the health care profession, complete with its highs and lows, the latter of which can include being sworn at, among other things.

I'm happy to recount this saga. Unfortunately, it does not come without a lengthy, but hopefully entertaining, prologue.

Prologue

In our medical school we're taking a course on how to interview patients. Sure, most of it is common sense, but in the day and age where doctors are taking hits on having poor bedside manner, the logic behind this can be understood. I have seen, and have heard first-hand accounts, of physicians such as a surgeon who would enter a patient's room, remove the surgery bandage, look at the wound, write in the chart, and leave, without so much as a word to the patient. Yeah, these cases are in the minority, but there are enough of them for the medical schools to start teaching doctors how to be compassionate and how to talk to patients and show empathy and feeling.

So, someone somewhere in medical school curriculum development land decided that there were not enough acronyms for med students to remember and separate them from the general public untrained in medical expertise other than through what they see in ER and Grey's Anatomy, and thus invented "FIFE."

The students in my class have taken very dearly to this acronym, and instead of talking about "asking a patient the FIFE questions" or "using FIFE," my classmates have taken towards stating it in terms of "FIFEing the patient." "In this interview I'll be sure to FIFE my patient," I have heard often, or in further abuses of the loose resemblance of the term another word in the English language, some students will say "FIFE your patient! FIFE them until you can't FIFE any more," or "I definitely FIFEd the _ out of my volunteer patient." No disrespect is meant to the patients, just to the dude who thought that "FIFE" would be a safe word to give to young men and women early in their medical training.

Even our faculty tutors sometimes use this term in a way that could possibly be phrased more gently. A medical student at my school was practicing interviewing a volunteer patient in our communication skills class, and called a "time out" because she didn't know what to ask. "Did you FIFE your patient?" the tutor asked. The patient, with a look of surprise and horror on his face, exclaimed, "'FIFE?!' You're going to FIFE me? What do you mean FIFE?!!"

If you don't know what this means, you're probably wondering by now what the heck I'm talking about. You are not alone, and I have chosen to enlighten you. FIFE stands for Feelings & Fears / Ideas & Impressions / Function / Expectations, and are headings for a number of questions that doctors can ask patients about their illness to determine where the patient is coming from.

For example:
F: "Do you have any specific fears or concerns?"
I: "What do you think might be causing this illness?"
F: "How is this illness affecting your daily functioning?"
E: "What are you expecting from this visit to the doctor?"

You get the idea.

Some doctors don't use these guidelines, some doctors do. Some avoid even the idea of it. A girl in my class told me that her clinic preceptor pretty much used "the anti-FIFE" - don't ask any questions about their feelings because there just isn't enough time if we're going to fit in 6 patients per hour.

In some cases, though, the FIFE questions can be very helpful. To demonstrate this, the course directors brought a standardized patient (an actor portraying a patient with an illness) who complained of wheezing and chest tightness. Questioning the class made it clear that we were all ready to assume that proper treatment would be along the lines of doing a lung test and prescribing asthma puffers; however, FIFE produced valuable additional information that would not have been discovered otherwise. The best example came upon asking the E portion of FIFE ("What are you expecting from this visit to the doctor?"). The patient revealed that she knew of friends and family that had suffered from heart conditions, and she wanted a heart test to rule out this possibility. Us budding physicians hadn't considered that the patient might have been hoping for this, so FIFE prevailed and we were all immediately and wholly convinced as to its efficacy and even stopped making fun of it just a little bit.

Saga

With that introduction I can now move in to the saga of my being sworn at.

I was in my third week of Family Practice clinic and was sent to a room to interview a patient. I walked into the room to see a gentleman in his late thirties peering out the window through the blinds. I wasn't sure how to approach this odd situation, so after composing myself I asked, "What are you looking at?"

"My car. I don't want my car to get towed," he said hurriedly.

He turned around to reveal a gentleman in his late thirties, I'm guessing blue collar, with blond spiked hair, an earring, and a large tattoo on his back and neck. He was the type of guy you might see get out of a beat-up pick up truck at a bar to have a few beers, watch a hockey game, and yell at the TV with his buddies.

I respected his implication that time was of the essence so I decided to proceed a bit more quickly, without asking about his family and hobbies and the like. I introduced myself as a medical student and asked if it was okay for me to interview him; he almost cut me off: "Yeah, yeah, do whatever you need to do, that's fine with me."

I proceeded ask him about the chest pain that had brought him in, and the typical questions about how long, how painful, and the like. "It hurts like hell," he said. I asked, "On a scale of 1 to 10, where 10 is the worst pain you ever experienced, how bad is it?" He replied, "Well, I have gout, and that is horrible pain. Compared to that, this would be like a 1. But this hurts like hell." I tried to figure out what that meant while I scribbled notes on my clipboard.

Once I had gotten a good idea of his pain, admittedly a bit flustered that I was thrown off my normal questioning routine by trying to rush the interview, I realized that I was running out of questions.

Without skipping a beat or showing any signs of distress, I immediately resorted to FIFE. I had the good sense to not ask this man about his feelings, and instead asked what he thought was causing the pain.

"My smoking, for sure."

Score one for FIFE.

I reached into my trusty FIFE question kit and carefully selected another question to present to him.

"What do you hope to achieve by coming in today?" I asked.

He stared at me.

"Um," I rephrased, "what are your expectations for this visit to the doctor?"

He looked at me as if I had just grown a third ear.

"I want to know what it is. I want to know what the fuck it is. Make the fucking pain go away."

And then the fateful blow:

"I just want to know what the pain is. Don't ask me any of your shit questions."

"Shit" questions?! I was devastated. I thought I had been armed with the tools of interviewing by my infallible supervisors, and yet here I had gone and agitated a patient to the point of cussing. How dare he call FIFE "shit questions"!!! FIFE had failed me. And it only went downhill from there.

I tried not to look too flustered and tried to wrap up as fast as I could. I asked if he wanted a flu shot, then I asked if he was taking any medications. He mentioned a drug for his gout, then looked at me and said,

"Dr. Milton knows about all my conditions. I've talked with him about all that already. My history is not your fucking business. Do what you need to do with this, and ask me nothing else."

Again trying not to act too flustered, and sensing something less than appreciation for my efforts, I ended the interview, and told him, "You know, I usually come back in with Dr. Milton, but if you prefer the doctor can just see you on his own."

His response was not what I expected.

"Oh, no, no, that's fine, I don't care if you're here."

A bit confused, and a lot flustered, I left and presented the case to the physician quickly, and hoped that this paradoxical patient would stop trying to test my limits. The doctor came in, diagnosed the illness, and wrote down a prescription. As the doctor was finishing up, he told me to take the patient's blood pressure.

I realized I had subconsciously edged my way as far as possible away from this patient and had my back against the wall, and so upon being asked to take his blood pressure I slowly made my way towards this man that I realized I had been distancing myself from.

He didn't make it easy for me, either. As soon as I put the blood pressure cuff on his arm and had inflated it with a single pump...he freaked out. He jumped and pulled his arm away.

"What the hell!?" he shouted.

I was pretty much at my wit's end, and shocked and confused as to why this guy was reacting this way to the very minor pressure that a blood pressure cuff exerts after only one squeeze of the bulb. I looked up at him in surprise.

"Just kidding," he said.

What the heck!? I'm not sure if there was something not right in this patient's head. My classmate suggested he might be bipolar. Either way, he was enough to make me seriously wonder about his sanity.

Postlude

(Any story with a prologue must have a postlude. It's just good Englishing, and I am a huge proponent of doing grammar correct.)

So that was my first experience being sworn at by a patient, and I can probably expect it to happen again. Fortunately, in the grand scheme of cusses that patients can direct towards their health care providers, this was very mild. At least he didn't start swinging at me or anything; heck, he didn't really even swear at me, just around me. And I couldn't wait to tell my interviewing class small-group tutor what the patient had said about FIFE.

I'll definitely be more selective about when I choose to pull out the "shit questions."

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