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March 27, 2007

Offering Reassurance

In today’s clinical skills session I saw a re-emergence of a problem that presented a few weeks ago whilst on another clinical skills session, the issue of offering reassurance to a distressed patient. Owing to our lack of knowledge and qualifications, I think some medical students feel powerless to address this situation.

A few weeks ago as a part of a cardiovascular examination I was measuring a patient’s pulse rate, a process which usually requires 15 seconds of concentration, and consequently, silence. Once I had measured their pulse, the patient asked if everything was OK, to which I replied ‘yes’. As a colleague later highlighted, this was the wrong thing to say because despite finding a pulse of 70 beats per minute there was no way of telling if this was healthy. Therefore I didn’t have the right to tell the patient that they were OK, simply because I’m not a doctor and have none of the skills required to diagnose or treat patients.

Sometimes when patients are concerned or distressed about their health it is important to be very cautious when offering them reassurance because, especially as a medical student, this may come at the cost of instilling false hope. What I should have said to the patient is that as a medical student I have no place to say whether or not they are healthy.

In today’s session I saw a stroke patient who was concerned about a persistent pain in her chest and right arm. She was very distressed and quite emotional, probably due to the symptoms of the stroke she had a few weeks earlier, and she was in tears when mentioning this pain in her chest. She asked if it could be a heart attack, to which I replied ‘there’s no way of knowing’. In hindsight this was probably the wrong thing to say as it may have worsened her anxiety by making her feel very uncertain about her symptoms. Again I think this was a case of blurting out the first thing that comes into your head in a rash attempt to allay the fears of the distressed patient in front of you.

In these situations I think it is safest to firstly take time to think and never rush to close silent moments, then mention that as a medical student you can’t offer medical advice. To ease the patient’s distress you can reiterate that there is a team of doctors and nurses caring for them. It may also be a good idea to call a doctor or nurse to chat with the patient.


March 24, 2007

Think, then speak!

After examining Mr R I moved on and attempted to interview and examine the next patient, Mrs B, with two of my colleagues. Here I learned absolutely nothing scientific or clinical, but I feel that what I did learn may be equally as important as all the clinical stuff.

I don’t remember much from the consultation because it started off as the worst consultation I’ve ever experienced, though I haven’t experienced many, I therefore just sat there reeling, half of me in slight disbelief at what I’d just said to the patient and the other half wishing I could crawl under a rock somewhere and lick my wounds!

Basically I started the consultation with the usual introduction and consent, everything was going swimmingly at this point, then I asked the patient how long she had been in hospital, to which she replied “a week”.

I can only speculate as to why I said this, but my reply to her was “oh, just a week”, and she didn’t react too well, she said something which I can’t remember, but something I haven’t forgotten is the fact that she pretended to have a gun in her hand and gestured to shoot me with it!! She even made the bang noise!!

She was pretty cheesed off and I was quite gutted at what had just happened, and as a result I didn’t pay much attention to what was said from there on in, I just sat there wondering why the hell I said what I said, and also wishing that the gun she had mimed at me with was real.

The three of us continued with the next agonising 20 minutes of the consultation (it was probably more amusing than agonising for my colleagues!) and at the end Jayne asked the patient if there was anything more she would like us to know, which was quite a good thing to say in hindsight. The patient then went on to say that she wished doctors (and medical students I assume) would consider that patients have lives outside hospital and are not just ‘asthmatics with names’, their life pretty much goes on hold when they’re in hospital and it would be nice for us medical people to think about what’s going on in their life and give them the opportunity to discuss their problems or offer them support i.e. liaise with social care workers etc.

During the consultation it turned out that the patient had a young child at home who was going away soon and needed help packing etc, on top of that she had ‘brittle asthma’ which is basically a very unstable form of asthma – this is the reason why one week prior to the consultation she was unconscious in the ITU and being considered for ventilation. And on top of all that she undoubtedly has all the same bills to pay as the rest of us, and while she’s in hospital the funds are going out but nothing’s coming in. And she’s been in hospital for “just a week”.

My only attempt at an explanation (not an excuse!) for what I said was that I had just interviewed a patient who had been in hospital for 4 weeks, so comparatively a week seemed like a very short time. And when you’re asking the patient questions for the sake of going through the motions of how to do a history, the answers to which don’t always mean anything to you, sometimes there are awkward silences which I for one am usually too eager to close (a problem I had with my DISC consultations). In this instance I chose to close the silence by blurting out a completely unprocessed and insensitive thought.

We will never know just from looking at a patient what kind of life they have and what stresses they are under so it’s best to start afresh with each patient and consider each person as an individual with unique circumstances. Obviously it was presumptuous to deduce that because one patient was seemingly coping OK with a 4 week hospital stay, another patient should be absolutely fine with a ‘mere’ 1 week stay.

This was another case of me being far too eager to close an awkward silence, and cramming my foot in my mouth as a result. As long as I can learn from this mistake hopefully it won’t happen too frequently in the future. Though I do expect mistakes like this to happen again because all us medical students have a phenomenal amount of learning to do over the next 40 odd years, and mistakes are usually quite good opportunities for learning, as long as you’re not learning about drug dosages etc.


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