Shut up and listen!

Posted by Patrick Lickiss on Aug 3, 2010 in Assessment | 2 comments

Think back to the last time you sat in your physician’s office.  Go ahead, I’ll wait.  With any luck it wasn’t for something life-threatening and was just for a routine checkup.  But let’s say something was bothering you and it exceeded your ability to treat it on your own (yes I know we’re all bad patients and hate going in and try to do everything we can to self-diagnose and treat).

I’ll give you an example.  I, like most people in the San Francisco Bay Area, have allergies.  Bad allergies.  So bad, in fact, that I basically live on Claritin twice a day from March to October.  Until recently, my allergies had never moved out of my sinuses.  This past year, however, I started to get short of breath from time to time and started to wheeze at others.  I finally decided it was time to get checked out.

When my doctor came in, he greeted me and asked what was going on.  I was able to respond: “Well I’ve been getting short of breath with exertion all of a sudden, and…” before I was cut off.

“Well, you’re a paramedic, what do you think is wrong?” was his reply.

“Honestly, I’m not sure, that’s why I’m here.”

“Could be exercise-induced asthma, I’ll write you a prescription for an inhaler, use it 30 minutes before exercise and come back if it gets worse.”

“Okay, but…”

“Oh, and if you get short of breath at work, put yourself on the pulse ox, just to see what the reading is.”

“Okay, thanks.”

“And just like that”, to quote Kevin Spacey’s character Verbal Kint from The Usual Suspects, “he’s gone”.

So needless to say, I wasn’t particularly thrilled about that interaction.  The short version of the outcome is that I got the allergies and the allergic asthma under control and that acupuncture and Chinese herbal medicine is a powerful combination.  But that’s another post.

HOW DO YOU TAKE A HISTORY?
This whole experience got me thinking, however.  What bothered me so much about this interaction?  I got treated in a short amount of time, so what made me so uncomfortable?  What it ultimately came down to, for me, was not being given time to tell my story.  A coworker of mine recommended “Every Patient Tells a Story” by Lisa Sanders and her chapter on history-taking validated my frustration.  Sanders brings up a good point:  patients construct a narrative of their symptoms and the events leading up to their onset.  They practice this narrative by telling friends and family and what is bothering them.  If allowed to tell their entire story, the likelihood is that the patient’s narrative will cover most of your basic questions about their complaints.

According to Sanders, a study was performed to determine how long physicians actually spent collecting a history from patients.  The encounters between the patients and physicians were videotaped with both parties being made aware of the recording (one would assume the physicians would be on their best behavior in this case).  The average time after asking the patient about their complaint until the practitioner interrupted with another question was 15 seconds.  Now think about your practice, how do you take histories?

SHUT UP AND LISTEN
Most prehospital practitioners are an analytical bunch.  We fancy ourselves detectives and enjoy the thrill of the chase.  We think several steps ahead during treatment and try to anticipate adverse and positive changes in patient status based on our treatments.  This all comes grinding to a halt during the patient history.  Patient are long-winded and circuitous when telling us about their complaints.  It drives us crazy that they miss key data points when telling us about what is going on: He didn’t tell me if the pain radiated!  Has she had sputum production?  So ultimately we start thinking about what our next question is going to be.  And how we are going to treat our patients.  And then, all of a sudden,  we can’t remember the last three things the patient told us.

What may work better is this:  ask a question and actually listen to the answer.  It’s crazy, I know, but it just might work.  Remember that your patient has a carefully constructed narrative to tell you and that it contains valuable information.  It may not hit every aspect of SAMPLE or OPQRST, but it can also tell you things that are not accounted for in any mnemonic.  Ask the question:  “What brings us here today, sir?” and then stop to listen to the answer.  You might be amazed what you hear when you shut up and listen.

WHAT IT MEANS TO OUR PATIENTS
In the ever-changing world of EMS, the issue of customer service comes up frequently.  Too often, patients are treated like machines in need of a mechanic.  The sooner we realize that the patient is just as important a part of the continuum of care as any EMT, paramedic or nurse, the sooner we can provide excellent customer service.  Making your patient feel like they have a valuable, vital part to play in their own care not only empowers them but improves their sense of well-being.  As we move toward treating the whole patient, not just the specific complaint, we need to remember to include the patient in their care.  When you actually listen after asking a question, you take a huge step in accomplishing that goal.  So next time you ask:  “What brings us here today?” just shut up.