Real-talk: What every clerk needs to know about conversation in medicine.

Mike Christie, Meds '21

     After a few months of clinical, I’ve come to the realization that effective conversation in medicine is its own art form. The physician has the role of immediately building trust and rapport with complete strangers, albeit while conversing with a wide diversity of people who present in a swirling myriad of contexts. Situations can change rapidly from patient to patient. Sometimes the circumstance surrounding a conversation is turbulent, emergent, panicked, or tragic. Other times, it’s jubilant, relieving, or routine. Combining the variety of situational dynamics with various personalities, at times I’ve found it both equally intriguing and challenging to communicate with the patient, or person, sitting across from me. From watching experienced physicians do their thing, it’s clear that effective medical conversation takes tremendous focus, tact, and humility. All of these docs admit that mastering the Art of Medical Conversation takes a career to learn. However, through their own examples, they’ve passed along some insights that have built a solid foundation off of which I’ve been able to learn. I think the basic - yet overwhelmingly human - essence of these principles make them something that every medical student should know.

    First off, you can’t have a conversation with a patient if they can’t hear you, you can’t hear them, or even worse – both! It’s okay to turn down the blaring TV in a patient’s room or close the door if there’s a commotion out in the hallway. You may have to raise your voice to what feels like an incredibly loud volume – we’re talking rock concert levels – when conversing with a hearing-impaired patient. Sitting down when at the bedside can help with hearing, and it erases perceived power dynamics at the same time. I have even seen a patient put in the earpiece of their doctor’s stethoscope while the clinician spoke through the bell. (Don’t worry, there were disinfectant wipes involved before and after). Regardless, setting the stage for conversation with something as simple as making sure you can hear one another is a critical, but often overlooked, first step. 

    “Patients don’t read the textbooks on how their disease presents!” It’s a line we’ve all heard at one point or another in our training, and it’s true. Patients typically don’t describe symptomology or progression of illness in a clear-cut timeline that perfectly matches classic clinical presentations. Obviously, part of the Art of Medical Conversation is carefully reconstructing the sequence of events in a medical history – that’s what we’re there for. The reality is, though, that it can be quite puzzling. Add in the pressure of limited time and it can quickly become overwhelming. It’s key to remember that it’s okay to pause, backtrack, and ask for clarification on timing of symptoms or events. Initially I was worried that patients would (incorrectly) view this as a result of inattention, however over time it became clear that they instead appreciated that I was being thorough. It’s more efficient to invest a few moments up front to avoid having to go back again at a later time. On a pertinent practical note, when patients struggle with remembering timelines or frequencies, using generalizations of timelines “days, weeks, months, or years” has proven highly effective at helping quantify a timeline.

    Part of collecting information from patients involves asking them a certain list of questions to ascertain critical details about their condition or clinical presentation. The challenge with this when first starting out is that it can be exceptionally difficult to focus on a patient’s answer to a question while at the same time considering what to ask them next. One helpful strategy for managing this is simply taking notes as you go along to more easily follow the conversation and have a quick summary available for review if you feel lost. Another key point is knowing that you are, in fact, allowed to pause and think for a few seconds! The interaction doesn’t have to be a rapid fire of back and forth. Pauses can feel tremendously awkward, however patients understand if you need a moment to consider which routes to explore with your next question. 

    If there was one thing that at first put me a tad off-kilter, it was experiencing first-hand that medical conversation is not sterile. What I mean is that it’s not always exactly like attending a formal Sunday tea party. This isn’t something that can truly be simulated in pre-clinical training. When we go to work, we deal with real, live human beings, and usually when they come to see us it’s not under the easiest of circumstances. Part of the job is speaking with patients who are anxious, angry, or frustrated. The reasons behind their attitudes, behaviours, and language choices are complex and multifactorial. It’s not our role to judge, and it’s key to understand that if a patient is upset, it’s usually not about you. To be clear, there is zero room for abuse of any sort, and although it can feel scary to do, you are never in the wrong for addressing it with your resident, preceptor, or the supports in place via the medical school. Having said that, there will be other situations that can challenge your patience, require great diplomacy, and drain your emotional energy reserves. Acknowledging that you are in one of these conversations is helpful for regulating your reaction and keeping a level head in the remainder of the interaction. Debriefing with the team can be beneficial to learn what other strategies team members use for challenging interactions. Lastly, recognizing that from a mental standpoint you may take some of your work home with you is also a valuable insight. It may be necessary for you to unwind a bit afterwards, and it’s okay to take time to do so.
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    Finally, it’s helpful to appreciate that as medical students our job is not to have all of the answers (at least not yet). The one thing we can do, though, is to make sure that in every single encounter the person sitting across from us knows that we’re there to take good care of them. An empathy-based conversation recognizes and respects the humanity of our patients. By dedicating ourselves to this axiom, we can always put the wellbeing of our patients first, and no matter what our discipline, that’s a part of the Art of Medical Conversation worth talking about.