One of the hardest things to juggle working in an environment where I am expected to see four patients an hour (that’s 15 minutes for each patient, including history/chart review/exam/administrative (read: charting/follow up coordination) time, if you’re following along), is trying to make sure I get to the root of what a patient is saying.
A lot of the time, many patients are bad historians. They noticed their new discharge “a while ago.” The lesions popped up, “I don’t know, three or four days ago? Maybe more?”
Many of them have low levels of health literacy, which the National Institutes of Health defines as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
The concept of health literacy is one we discussed in nursing school extensively. One of the first steps of the nursing process (and the philosophy that makes me proud to be a nurse) is “Assess readiness to learn.” Many people have had such horrible experiences in seeking health care that they do not seek out medical care often, do not know much about their own bodies, and find going to the doctor/nurse practitioner’s office a terrifying and disempowering event. When you combine all of these factors with the concept of reproductive health care, shame and stigma get added into the mix as well.
With all of these factors combined, it does not make for a very good starting point for many of my patients, and assessing readiness to learn and address the most important aspect of what care I’m giving is essential.
Many times, a patient will make an over-arching statement that is vague and broad, such as, “I can’t use any birth control method other than condoms.”
The actual meaning of what my patient is saying is buried deep within this statement, and could be easily missed. Does she mean that she’s tried everything and condoms are working for her and her partner? Does she mean that she doesn’t think she can afford any other method? Does she mean that she doesn’t want any hormones and believes the male condom to be her only option?
This is when I break out my favorite phrase, my most trusty tool, and closest ally in getting to the root of what my patient is saying.
Tell me more about that.
It’s a simple, non-judgmental, door-opening line. It is a transport into my patient’s thought process, and allows them to open up to me without fear of shame or degradation.
One of the hardest things to do in practice is take a history and assess current symptoms, when they started, and other important factors that give us clues as to where to go next. It may seem simple, but most of the time, patients don’t lay out their stories in a way that fits into the way we are taught to gather histories.
We are taught a handy mnemonic in school to assess symptoms called OLDCAARTS, which stands for: Onset of symptoms (when did it start?), Location (Point with one finger?), Duration (If this has happened before, how long have you had this problem?), Characteristics (Sharp? Burning? Aching?), Alleviating factors, Aggravating factors, (What makes it better, what makes it worse?) Radiation, (Feel it anywhere else?) Timing, (Morning? After intercourse? All the time?) and Severity (On a scale of one to ten….)
Do you think I have ever had a patient that knows all of this information, can detail in accurately, and most importantly do that in about 5 minutes? If you guessed no, you win.
Most patients will tell you what they believe is causing their problem (sometimes a helpful clue, sometimes not). Some will tell you, “I have a yeast infection I think,” and then just say, “well, it feels weird down there.”
Teasing out important information to gather a complete HPI (History of Present Illness, or basically, an answer to the question, “Tell me about your symptoms), is like a puzzle.
It is your first clue into what physical exam you need to do, what you’re thinking could be the problem, and how you’re going to solve it. When a patient gets stuck, or can’t tell you exactly what’s going on, it can be frustrating. But taking a step back and investigating what brought THEM in today, not what the chart says, not what kind of a visit they are scheduled for, not what you think needs to happen, can open doors wide for a patient that is unsure. A patient that doesn’t really want to be there. A patient that is scared. A patient that is frustrated.
So, tell me more about that.