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Tug-of-War

Jo Marie Reilly

As I teach first- and second-year medical students to take patient histories and to perform physical examinations, I always feel humbled and privileged–energized by their compassion, enthusiasm and facile, curious minds.

Occasionally, I feel particularly challenged–especially when I’m teaching a student who, though bright, is struggling to acquire some of medicine’s basic skills. As we journey up the learning curve together, my responsibilities can conflict: as a teacher, I want to nurture an aspiring student physician, yet as a physician, I must ensure that patients receive appropriate care.

Now, sitting quietly in the corner of the room and watching a young medical student interview a county hospital psychiatric patient, I begin to feel this tension.

“What brought you into the hospital?” the student queries nervously.

Small and reserved, she’s quite a contrast to her patient–a burly, imposing middle-aged man, his body splattered with tattoos of birds of prey and firearms. He folds his arms tightly across his chest, and a large cross sparkles on his neck chain.

“It’s when I tried to commit suicide on the bridge,” he responds agitatedly.

There is a long, awkward pause. “So…what medication did you say you take?” she asks.

“I take respiridol. It’s for my voices,” he replies flatly.

The student clenches and unclenches her hands.

“What about drug allergies?” she asks. “Do you have any drug allergies?”

“No.” He stares at her blankly.

“Alternative medical therapies?”

“No!”

She fidgets with her papers, looking through her history-and-physical book for the next question to ask this obviously disturbed man. Her eyes dart around the room’s harsh, white walls, devoid of any mirrors and pictures. The stark surroundings make the interview even more intimidating.

As a seasoned clinician, I feel frustrated by the fumbling interaction unfolding before me. But as a teacher, I feel compassion for the student’s discomfort with this emotionally fragile man and hope that she can find a way to connect with him. I continue observing silently.

The student locates a phrase on her mental-status sheet that seems to give her comfort.

“Your mood,” she blurts. “How would you describe your mood?”

“Angry!” he shouts, picking furiously at some invisible specks of dust on his hospital gown and flicking them off with his fingers.

“Oh.” She glances nervously past the bed curtain to the guard watching curiously from his doorway post.

Okay, I think. It’s time for an attending-physician rescue. I stand up and walk to the bedside.

“Mr. Adams, ” I say, “tell me about the bridge. You must have felt pretty desperate to want to end your life.”

He looks at me, relaxing a bit. “Yeah, I jumped from that bridge, but that fisherman pulled me out. Damn well near froze in that water.”

Thinking that I’ve jump-started the interview, I nod to the student, who’s been frantically scribbling down our conversation.

“I haven’t asked you yet about your past surgical history,” she stammers.

He simply looks at her.

“That’s quite a story,” I interject. “What made you so anxious that you wanted to jump from the bridge?”

“It was those voices again. When those voices come, it’s all over.”

The student looks at me; I raise my eyebrows encouragingly.

“How about immunizations? Did you receive your childhood immunizations?” she asks.

“Immunizations?” He looks at her strangely and begins to tap his foot against the bed. “What are immunizations?”

“Well Mr. Adams,” I say, “I actually think it’d be important to know more about those voices. Tell us about them. What do they tell you to do?”

“They tell me I’m worthless. They tell me to hurt myself.” Looking distressed and ashamed, he gazes at the wall.

I pause, giving the student another opening.

“Let’s see,” she says, looking at her notes. “Did you ever do any military service?”

I look over at her again, trying to conceal my exasperation. Does she just not get it or what? Time to bring this painful interview to a close.

“Mr. Adams, you’ve been so kind to talk with us this morning. Your voices sound like they are very scary, and they cause you to do some unsafe things. How are your voices now?”

“They’ve quieted down since I got back on my medications,” he says. “They’re not telling me to kill myself anymore.”

I nod. “I’m so glad that you’re feeling safer now. We’ll make sure the social worker gives you enough medicine so that when you leave the hospital you can keep your voices down. Can we do anything else for you today?”

“I just want to rest now. I’m pretty tired from all this talking,” he answers, closing his eyes.

Out in the hallway, I turn to the medical student.

“How do you think it went?” I ask.

She glances at her notes, looking distracted. “I think it went pretty well,” she says. “I got almost everything–but I did forget to ask him if he had a family history of diabetes.”

I sigh inwardly. How can I give her feedback that is constructive and tactful? How much of her stumbling is due to her youthful inexperience and to the intimidating environment? With more maturity and less nervousness on her part, will her communication skills blossom?

The inevitable doubts set in. What is my role and responsibility as her teacher? How can I help her “get it”? What if, despite my best efforts, and those of my colleagues, she still cannot adequately listen and respond to patients? I dread the thought.

At such challenging moments, I think of my professional vows–the Hippocratic Oath’s admonition, “Do no harm.” As a teacher, I am called upon to do no harm to this hopeful, aspiring student physician. As a clinician, I must ensure that no harm be done to the patients she serves.

I must dig deeply for courage, patience and wisdom.

And so continues this tug-of-war.

About the author:

Jo Marie Reilly is Associate Professor of Family Medicine at the Keck School of Medicine of the University of Southern California (USC), where she is Director of the Professionalism and the Practice of Medicine course and Assistant Director of the Introduction to Clinical Medicine course. She is also a member of Pulse’s Editorial Board.Writing helps me connect with the power of humor, joy and compassion in the work that I do, and in doing so helps me balance my professional life, patient care and personal life, which includes spending time with my family.”

Story editor:

Diane Guernsey

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Comments

52 thoughts on “Tug-of-War”

  1. Part of the battle of becoming a well-rounded PA is the knowledge that we gain throughout the semester. Of course, the rest of the battle to becoming a PA is the patient to physician interactions. I have to admit, it is hard at times to find the right words to say in such uncomfortable times. I just have to remind myself that these patients are people to who are just looking for someone to be there for them. Though it will take time, all we can do as students is to expose ourselves as much as we can so we can get to the point where we are able to handle these types of situations. There is no script for personal emotions, so the one thing we really have to work on is how to be human. This article did a great job capturing the struggles a student goes through regarding personable interactions. We always want to say the “right” things but sometimes the “right” things is not what a person is asking for so we have to remember to work in both the knowledge we gained and personable emotions into our practice.

  2. Reading this story, I tried to imagine myself in the student’s shoes. I try to tell myself I would’ve handled the situation better, but I’m not sure I would have. It is one thing to practice interviewing when studying; it’s a whole other ball-game when doing it in a clinical setting. The student was trying to go back to the basics of her teaching, but she was missing the most important part of getting the patient’s history of why they are currently hospitalized. I think one of the best ways to help the student would be to reiterate the importance of finding out why they are there. The other information is helpful, but not nearly as important.

  3. As a current student myself, I can understand how nerve racking this interview would be. I felt like the student was falling back on the basics that we learned this summer, asking about immunization etc. because of nerves and lack of experience. I was surprised at the end when the student had thought the interview had gone well. The much more pressing issue at hand was not be addressed by the student. The student should have addressed the suicide attempt directly and inquired about how the patient was currently feeling and if they were still actively suicidal and hearing voices. The student also didn’t address or acknowledge the emotions of the patient other than saying “okay”. The teacher tried to get the student on the right track but was unsuccessful and had to take over. I can understand the frustration of not only the teacher but also the patient, who was understandably exhausted.

  4. I never thought of the fact that professors have a tug-of-war going on inside of them to try and teach us how to be the best Physician Assistants we can while trying to comfort us in learning a plethora of new skills . I also found it interesting how the professor really tried to guide the student into the right set of questions but she was more concerned about his PMHx instead of connecting with him on some sort of emotional level. I think connecting with patients is one of the harder things to overcome as a student in the medical field.

  5. I think this article outlines the continuous back and forth a lot of students have in their head when asking a patient questions. We are trained and told to always cover the 7 factors, allergies, medications, any significant medical illnesses, and so forth. However, this is a perfect example where abandoning that strategy is more beneficial to the patient rather than covering what we think we need. In order to help some patients, it is best to focus on what’s at hand rather than what we have been taught in some instances. In this case, this patient is obviously distraught and angry and needs someone to show genuine compassion towards his situation, and the 7 factors would simply not help this patient. It is always important to look at the overall situation and patient, because as a clinician it is important that we can be flexible and adaptive to unforeseen interactions with patients. We are taught that medicine and illnesses are not a one size fits all, and we must keep this in mind with each patient interaction

  6. As a PA student just starting to learn how to effectively interview and communicate with patients, this was difficult to read because I sympathize with the student and can imagine myself having these same struggles. When first approaching uncomfortable and unfamiliar conversations with patients, it can be hard to find the words to piece together effective questions.   I think this article is a good reminder to students to keep the patient’s needs as the top priority and focus on the paperwork second. And as the seasoned doctor expressed, practice and experience make situations like this easier.

  7. As a student, I think that it’s drilled in our heads to get the basics from the patient’s history. (If we don’t get the history, we don’t get the points). The problem with that is, we become so laser-focused on getting the patient’s background information and by doing that, we don’t see our patient’s real needs. We want to pass and we want our preceptors to be proud of us for getting pertinent background information because of how important history is to us. Mental health is so important though and a quick heart-to-heart or showing some empathy will build trust with the patient but also explain a patient presentation that may not align with a specific diagnosis.

  8. Behavioral medicine is not like any other medicine topics we have seen before. It has a lot to do with being able to talk to the person and direct the history based on what they are saying rather than focusing on the definitive step by step history we have been taught from day one. In these settings immunizations and family history about diabetes isn’t as important as the situation that is occurring at this moment. The biggest thing is to make the patient feel like they are being listened to and acknowledged.

  9. This article demonstrates you cannot judge a person based on their story. There are many challenges in life and some things aren’t always in control of the patient. Reading the medical record beforehand is a good way to get a short history but it is not the only thing you should read and you should never base judgment on your patient ever, but especially from a few sentences in their chart. Behavioral medicine illnesses are not something to judge someone over, because they cannot control their illness. Addicts you see also sometimes do want to change their habits and shouldn’t be lumped into a broad category.

  10. Through the summer semester of the didactic year, we were taught as students how to take a proper history including all the questions the student was asking the suicidal patient. However, this article brings light to how students can be so focused on medicine and getting all the information, that they forget to actually listen and assess the patient sitting in front of them. If a patient is there for an issue that they may not feel comfortable talking about, it is best sometimes to just let them talk and prompt them when they stop or say something worrisome, such as the voices the patient hears. It is important to always make the patient feel heard, and in this instance, it is obvious that his allergies are the least of the provider’s concern…at this point. Overall, I loved this article!!

  11. I think that the article really outlined struggles we may have during our clinical experiences. It really outlined things I need to be thinking about during my interviews and how important it is to treat the patient as a human being. This isn’t role play anymore, this is real life with real patients. It is very important to respond properly to how they are receiving you and the questions you ask.

  12. As students in the medical profession, we can be so preoccupied with getting everything perfect on paper, that we forget to look at the patient and how they are feeling. This patient was telling her about a sensitive subject and she was dismissing him the whole time. In a moment like that, medical providers need to be empathetic and understanding. The patient was getting aggravated because he felt the student was ignoring him. In this type of interview, the traditional way may not be the best way to interact with the patient. We have to be able to mend and change interviewing styles to fit our patients best.

  13. As a student, I can understand and empathize with the student in this situation. When faced with an uncomfortable or unknown disease/situation one can easily become flustered. However, as future medical professionals it is our job to be able to handle and control a situation such as this. When the professor stepped in and tried to lead the student down the right line of questioning, the fact that she continued to ask questions that are not of primary importance is incredible. The questions she was asking were not “incorrect”, but one must remember that based on the pt’s situation their is a level of importance to those typical questions asked of pts. Regarding the professors tug-of-war, I believe that with time this student will improve her history-taking skills. I do think the professor should sit with her and discuss what she needs to improve on making sure the student truly understands why she did not do well with this pt encounter.

  14. Breonna Kali Hoffman

    I think this article is very important for all medical students and providers to read. We are often told and taught to follow a script and to get that information right away. We are also taught to redirect the patient if they get off track. However, when it comes to behavioral health issues, it can be difficult to follow that script. Those things are still important to know, but maybe not at first. It may be more important to focus on the mental/behavioral health issues and get to the other things later on, especially in this story above. By just allowing the patient to talk about their behavioral medicine issues, we possibly could better help them. After reading this story, I better understand how to approach mental health issues when talking to a patient.

  15. Katelyn O'Connor

    As a medical student, I cringe and sympathize for the interviewing student. We are always taught to redirect the patient in order to get a thorough medical history. I have had a similar experience with my very first hospital visit; my patient was in deep emotional distress and they vented to me for about an hour before I could really start asking questions. I probably got one of the worst medical histories out of all my classmates, but it was worth it because the patient thanked me for my listening and comfort. This article further validates that many patients only need someone there to validate their feelings, and this takes priority over getting a good history.

  16. This article really highlights the importance of seeing every patient with an open mind. In this specific example, the provider already conceived an idea of how the patient interaction was going to go just based on what the provider read about the patient. However, once the provider met the patient in real life, the encounter was far from what the provider was expecting. I think this article really shows that even though you might have the facts or medical history on a patient, you truly do not know how the patient is going to bring those facts to life until you meet them.

  17. Madalyn Harbaugh

    I found this article very interesting because I feel it exemplifies the importance of paying attention to the patient. As students, we are taught to empathize with our patients and make them the center of our medical interview, however, at times it may be easy to be so focused on the important information we need from our patients we forget to actually engage in meaningful conversation. I think this article showed the importance of attending to the patient’s current needs and emotions rather than focusing on what is needed for the medical chart. Although it may be easy to get overwhelmed especially if a situation is uncomfortable or unfamiliar we should remember to first show compassion toward our patients.

  18. I feel as students we often get caught up in the documenting and practical aspects of patient encounters when in reality, it is more important that we are listening and engaging with our patients. It can be easy to get distracted by everything else and forget what the patient in front of us may be feeling. However, it is our job as clinicians to ensure that the patient feels that they are heard not only in behavioral medicine, but in all specialties. We must remember that they are people too and by listening to them we may be able to help them more in the long run.

  19. The interaction described above demonstrates the importance of putting the patient first. As students we are given a “cookie-cutter” example as to how to conduct a patient interview, which works most of the time. However, in some instances, healthcare providers need to branch off of how they are taught to conduct an interview inorder to get the most information possible while still showing compassion and sympathy towards a patient. If the doctor had not drifted from the usual interview script, the student would have missed some important information about the patient’s story which could have altered the treatment.

  20. \Behavioral medicine disorders typically forego the usual H&P. The article explains how important it is that the patients current well-being and mental state be approached first. I think as a PA student it is easy to follow H&P guidelines to a T in order to learn what to do as future providers. When presented with an uncomfortable situation like the student in the article, it is easy to turn to notes for a sense of comfort. In behavioral medicine, it is more important to understand the patient and think of their personal feelings.

  21. This article was very relatable because I feel that, as students, we always go into a patient encounter feeling like we need to get all the patient information and don’t always focus on actually hearing the patient’s story. In situations such as the one the article described, it is much more important to listen to the patient and let them confide in you about how they are feeling and not to worry so much about other irrelevant details that can be acquired later. 

  22. The article depicted an interesting story that I feel like most of us can relate to or at least be compassionate towards. As students, we are often focused on doing things perfectly and doing them the textbook way. However, in this situation it is obvious that the student was too caught up in making sure she had all of the “textbook” information that she forgot to assess the patient as a person, not just an assignment or a case. While things such as medications and past medial history are important we cannot forget about the person in the bed! The physician was compassionate towards the patient and did not necessarily treat the patient or do anything for him, but she listened and gave him an outlet for his feelings and let him know that he was heard. 

  23. This article highlights the importance of focusing on the individual patient and his needs, rather than simply reading questions systematically from a booklet. In this article, the student is having difficulty with finding the right questions to ask the patient and instead is asking questions that are not at all important to his problem. It demonstrates the value of concentrating on the patient’s current complaint, as obtaining a complete history, including hospitalizations, surgeries, etc., is not the most important element of this appointment. The attending-physician struggles between wanting to help the student learn and ensuring that optimal and quality care is provided to her patients. As medical students, it is important that we focus on asking questions that are pertinent to the patient’s chief complaint, rather than strictly gathering all the facts from his or her entire medical history. It is also important to understand that our patients are human with feelings and will often respond better to compassion and an understanding ear to listen.

  24. After reading this article, the importance of personal interactions with patients was particularly highlighted. Clinicians must develop a sense of compassion and understanding while talking with patients to truly understand what someone is going through. In my personal experience, I have found it much easier to talk with patients whenever I put all my paperwork down and just listen to what they have to say. I have started to find an approach to interviewing a patient that works for me. However, the scenario in this article probably happens way too often. It is important that as future clinicians we don’t develop tunnel-vision and only ask for information that is needed for a write-up. In this example, there was so much more to the story that could have been discussed if the student showed more confidence and compassion.

  25. As a student, it is very easy to understand the rut that the student found herself in when trying to check all of the boxes that we have been taught are so important; however, to fail to talk to the patient like a person and make them feel comfortable and safe. This article highlighted the importance of putting aside our books and to look at the patient in front of us and simply have a conversation with them. Yes, it is important to talk about their past medical history and their drug allergies; but it is just as important, if not more so, to make the patient comfortable and build a bond that you can continue to work on and grow through further patient encounters. Finding a way to work past the pressure to gather what has been deemed the most important information in a set way and make the patient feel safe is a very hard skill to gather but one that will undoubtedly come with time.

  26. As a student in the medical field, it can be difficult to communicate with patients in uncomfortable settings especially because we are strictly taught to make sure we ask all the right questions without leaving anything out. It is easy to forget that it is most important to listen to the patient and understand why they may be feeling a certain way. With patients in Behavioral Medicine it may not always be relevant to document every detail, instead the focus should be on forming a better relationship with the patient in order to enable the patient to speak freely about their current mental illness. It is often difficult for students to prepare for these situations as communicating with patients is still a new skill that needs “fine tuning”. I felt that this article was very interesting and helped me get a better feel for the field of Behavioral Medicine.

  27. In the article titled “Tug-of-War” I think that is evident that while interviewing psychiatry patients, as a provider, you have to apprach the patient interview differently. Some aspects of the standard, by the book interview, are not as important as listening to the patient and asking compassionate questions that pertain to the patients situation. I think as PA student, I am always trying to systamtically approach the interview in order to obtain the necessary information that many of the important questions can be forgotten or over-looked. I think that this article is a good reminder to caregivers to approach each patient individaully and provide the compassion and understadning that the patient is in need of.

  28. As a student, it can be very easy to focus on “checking all the boxes” during a patient interview. While the student’s collection of drug allergies and medications is important, the most important thing in the room is the patient himself. The importance of the checklist and paper is minuscule in comparison to the distraught man brought in by attempted suicide. This emphasizes how checking those boxes will NOT tell you all that you need to know about the patient, but listening and attempting to understand how your patient feels and why he may feel that way will. A personal experience this brought me to reflect on was a young teenaged girl who came to her pediatrician with her father complaining of stomach pain. Her pain turned out to be a physiological manifestation of depression brought on by stressors involving school and her parent’s divorce. If the clinician had honed in on the stomach pain and did not consider the whole person, she may not have received the proper care. I understand the author’s frustration with her student because the student’s interview approach was inappropriate for her patient. It is important to remember that our patients come first regardless of how uncomfortable we may be with the topic of mental illness.

  29. As a PA student, I understand the student’s compulsion to systematically collect information like we are taught to do regarding most medical complaints, but this article highlights that behavioral medicine can be an entirely different beast. The interview process is the most important aspect, and due to the nature of the complaints, the usual method of collecting history might have to be thrown to the wayside. Collecting a complete medical history becomes less important than fully exploring what the patient’s current problem is. Due to the nature of some of these illnesses, getting the information needed to make a diagnosis is a more convoluted and difficult process. Students need to focus their attention on that instead of checking off boxes.

  30. I think this article is very important for students to read. I think it does a good job at highlighting the differences between the type of history we are used to taking and the type of history that is better for behavioral medicine patients. In this type of history it is better to look at the patient as a whole and figure out why they are facing these issues, rather than asking irrelevant questions about their medical history. It is clear that it is important to get to know the patient in order to better treat them.

  31. As an aspiring PA, I think this article is frustrating, but a good learning experience at the same time. I think this article emphasizes the differences of behavioral medicine compared to other medical fields, and how it needs to be approached differently. In the introduction class, Dr. Cavalet stressed to all of us how important it is to treat the patient as a human. Taking a patient’s history is critical in the diagnosis of these behavioral disorders because most of them are clinically based, and the medical student didn’t even address the patient’s main concern. Instead she was more concerned about the process, and not the patient.

  32. I will never forget the first patient I ever dealt with that presented with sutures that needed to be removed from her wrist. It was obvious the cause but at that time in my career I was unsure as how exactly to go about that “uncomfortable” encounter. So I did the only instinctual thing that I could do and I sat beside her and asked her if it was okay if I asked what happened. This encounter went from a methodical and sterile patient triage to a comforting encounter that put both myself and the patient at ease. This reflection reminds me very much of my first encounter, stumbling to get the “important” information and almost forgetting that this patient is a person not a diagnosis or a medical record. I appreciate the “tug-of-war” that the professor describes within herself because she also has to step back and realize that this level of comfort and tact with a patient comes from experience and practice. The most important message from this reflection truly is to remember that our patients are more than a complete history and physical and that sometimes the “rules” go out the door because the interaction and communication is more important and can provide more information than ever imagined.

  33. As a PA student I found this article really relatable. I think it is really easy to feel as though in order to take a good history you need to ask every single question on the sheet. However, what is most important is addressing the reason for why the patient is there. People want to feel heard and understood. They do not want to just seem like another check off the list of today’s work. This article serves as a really good reminder to not loose sight of the patient’s situation and to work on being a good communicator.

  34. As a PA student myself I can totally relate to this medical student’s nervousness. In school they teach us how to take thorogh history and tell us to try to take as much informtaion as we can. But in real life sometimes its not even possible, sometimes talking to patient and getting to know his core issue is far more important than recording his history. As a student she was trying to do what’s been taught but she forgets the element to take holistic approach and try to make the connection first and make the patient comfortable because this particular patient has mental illness, so its important to focus on his mental health to provide proper care. The other information (allergies, past mesdical Hx) no dought has alot of important but can be put aside for a while depending on the case. It is crucial for all current or future clinicians to build a trust with patient inorder to give better care and I also think it comes with experience.

  35. As a medical student, this article really resonates with me. I too, like the student discussed in this article, at times struggle with the interview process. But what is different here is that, while you are taught to check all the boxes and collect certain historical information, sometimes that needs to go by the wayside. The patient in this article clearly has more pressing problems to discuss that outweigh some elements of the history. The author of this article, being an experienced clinician, picks up on this and tries to focus in on the patient’s voices and attempted suicide. This is when medicine becomes less regimented and the clinician takes on a role of friend, listener, and supporter. This may take time to develop, but it is a crucial part of the career and caring for patients.

  36. This article depicts an interaction that likely happens all-too-often with new medical students. In school, great effort is put towards teaching medical students how to take thorough histories proficiently. However, sometimes it appears as though this does not transfer over to the real world in terms of patient interviews. With a patient presenting with a symptom as sensitive as in this example, it is clear that students need to learn to effectively and compassionately communicate with patients. This is crucial to taking a good history and understanding the patient as a whole.

  37. This article highlights the importance of taking a holistic approach of care, rather than a purely physical one. Physicians are responsible for the overall health and well-being of their patients. This includes both the physical complaint of the patient, as well the mental and emotional aspects as well for all will have an impact on diagnosis and treatment. As student’s we are taught the objective facts of lab scripts and physical exam findings that coincide with different disease processes, as that’s what we’re being primarily tested on. However, it is imperative that as providers, we take into account critical information obtained from the patient’s history. By gathering the necessary information, we are able to approach the patient’s physical complaint in respect to their overall well-being. We can further better this practice by building good relationships with our patients. By providing a comfortable environment, we allow the the patient to share more about their life and emotions in greater detail, leading to a more specific diagnosis and/or treatment plan. Approaching the patient as a whole and not a ‘number’ results in accounting for their mental and physical well-being. Embodying a more holistic outlook allows us to supply individualized care that will result in the betterment of our patient’s overall health.

  38. This article highlights the importance of recognizing patients as human beings rather than “just a diagnosis.” It can be challenging as a healthcare provider because all too often it can be easy to get wrapped in acquiring “the facts.” It is crucial to establish rapport with patients to ensure the utmost care for them. After reading this article, I will make sure to be extra vigilant to place extra emphasis on understanding my patients thoughts and feelings as well as potential struggles with different medical illnesses.

  39. I believe as an aspiring medical provider it can be difficult to break structured habits such as taking a thorough history. However, there needs to be a balance between obtaining a history, and tending to the needs/concerns of the patient. Allergies, medications, and past medical history are all excellent components to obtain when seeing a patient, but if the patient is in a time of need it may be appropriate to put those off until later. It is worthy to note that an introduction and history will differ by setting and patient. This is especially true in behavioral medicine. The interaction between the medical student and the patient used in the article was a great example of a how tending to the current needs of the patient are more important than getting subsequent information. It was obvious the patient did not want to discuss other aspects of his life aside from what was causing him trouble currently. I believe the medical student would have realized this had she taken the time to listen and genuinely inquire how the patient was doing. The interaction would have most likely gone smoother. With this being said, I think it can be very difficult to turn off the “robot-like” switch sometimes to modify the generic history taking strategies we are accustomed to using. In the case of behavioral medicine, turning that switch off and learning to adapt to patients in order to establish proper rapport is of great value. I think this article was a great reminder for myself to always have an open mindset when it comes to interacting with patients. I sometimes need to focus on putting myself in the patient’s shoes and considering how they are feeling as well.

  40. This was a very interesting read! As a PA student, I hear stories from other students about how their day went in clinic while on their rotations. However, it was insightful to read the preceptor’s perspective in this anecdote. I like how Dr. Reilly is cognizant about her different roles in this scenario, as a clinician and as an educator, and how she realizes that she must balance the two in order to give both the patient and the student justice for their purpose of being there.
    Reading about how the student was so adamant on getting the patient’s medical history instead of focusing on the patient’s serious complaints was unsettling. However I could understand why she may have acted the way she did. Sometimes when we are stuck or uncomfortable, we try to follow the “script” we are taught in school in the hopes of doing something right. We are taught to systematically obtain all the information for charting, that sometimes we may forget that this person in front of us is not a chart or just some patient; this is a human being seeking help and guidance. We are taught how to obtain medical histories and diagnose illnesses, but we must also know the importance of interpersonal skills and communication with the patient. This article was helpful to understand that when we are on rotations, we must practice both our medical skills and our communication skills.

  41. As an aspiring physician assistant student I can understand the nervousness that caused the youthful medical student’s thoughts to be clouded, which the physician understood. However I was concerned at the fact that when the physician tried to interject and steer her in the right direction with questioning she failed to identify this on multiple occasions. As a student we are taught to gather a good history and to hit all of the information required, but we must also understand that in some situations, this one specifically, getting immunizations and other medical information is not as vital. Sometimes it is more important to talk about the patients thoughts thus establishing and demonstrating to the patient that we are invested and that we care about them as a patient. Although this encounter may have been difficult for the student it is important to all other students to be aware of this so they can be prepared for a situation like this in the future.

  42. Nicholas Anderjack

    This article was very helpful for illustrating a new perception that often occurs in medicine that often is not discussed or evaluated. Most of the time, we believe patients are in the hospital to get better and are usually accepting of their situation, remaining calm. But sometimes situations like this can occur and there is a certain approach one must take to give the patient the care and comfort for the patient regardless of their current mood. Compassion and reassurance that a patient is still a human and is being treated by someone who has humanity for people will treat the whole person and not just the disease. Having a connection with a patient will help to keep the patient engaged and understand that someone is listening to them and is willing to help.

  43. I really enjoyed reading this article. It perfectly illustrates how we, as care providers, can get so caught up in a systematic approach to obtaining information, that we fail to realize the reason we entered the health field in the first place; the patient’s well-being. We must understand that patient’s cannot connect to someone who doesn’t care for them as a whole. We need to first connect with the patient, show empathy, and true understanding, and then dig for whatever information may be necessary for providing the patient with the best care possible. As a student, this article was very relatable and definitely information to learn from.

  44. I thoroughly enjoyed reading this article about this patient-student interaction, and I think it’s a great way to get into the behavioral medicine mindset. Although there were clearly some red flags as to how the student was interacting with the patient, it was also very relatable. Every patient needs approached in a different way, especially in the mental health field. It is definitely a challenge to be able to always be compassionate and listen to the patient, while trying to collect all the vital information for the sake of the patient’s health. I’m excited to learn more about how to talk to and treat patients with mental illness so that I can provide the best care possible.

  45. This article offers a great perspective. Often we are taught all of the information that we need to gather and the facts, but it is hard to teach an individual how to be personable and relate to the patient. Knowing how to appropriately engage with a patient is difficult. There is no way to teach how to react to any number of scenarios that will happen. Time and experience is important in learning how to relate to patients and show empathy while also demonstrating confidence. Medicine is an art and although we often expect situations to be black and white, they almost never are. Teaching and learning are both difficult to balance. You want to let students learn and gain experience. Yet it is important to ensure the patients safety.

  46. This article is a great example of the fact that medicine is not all about memorizing facts and mindlessly reproducing information. There is an art to it. As with all art, it takes time to perfect. The only problem is that failure may lead to someone getting injured or harmed. It is certainly a lot of pressure for both the students and professors to endure. Hopefully with time, all medical students will make the important realization that connecting to the patient and understanding their thoughts and feelings is just as important as reproducing facts.

  47. This article is a great way to dive into the behavioral health model because it depicts the struggle that every medical professional student experiences. As a current Physician Assistant student , I can relate to this article because it can be quite the balancing act of trying to get enough history from the patient while still trying to relate to the patient and form a connection with them. Sometimes we get so caught up with hitting all the patient history questions that we forget to read the patient’s body language and pay attention to what they are actually telling us in order to adjust the patient interview accordingly. We must remember to slow down, listen to the patient and make it a priority to connect with the patient.

  48. There is a large amount of pressure on students to obtain the entire medical history of their patient in order to give a good presentation to their preceptor. Asking the right questions and obtaining a pertinent history can sometimes be so important to a student that a connection and compassion for the patient may fall second. This article is a good reminder that it is important to listen to your patients and take time to slow down. In this situation, the patient seemed to appreciate when the attending physician stopped asking so many history related questions and spent more time connecting with them. I think this article teaches a good lesson for all healthcare providers.

  49. The article “Tug-of-War” by Jo Marie Reilly appeared to me as a common occurrence among unseasoned medical providers. Putting myself into the shoes of the young medical student, I know I would have responded the same way she did, unsure of how to react properly to the patient’s response or ask the appropriate questions. The author’s depiction of how she handled the situation puts into context how not everything is by the “history-and-physical book”, but rather, based on the patient and what their chief complaint and symptoms are. Additionally, I felt that this particular interaction displays how addressing behavioral health complaints is slightly overlooked in learning how to take a proper history and physical. Most of the time, histories and physicals are centered on a disease that can be measured with a stethoscope or assessed with a range of motion test, when rather we forget to assess the proper mental status or divulge further into a complaint from a patient that is a “red flag” for behavioral health. However, providers struggle daily with teaching students how to care for a patient and providing for the patient themselves. When a hurdle comes in the way of this balance, such as watching a student struggle to provide the proper care to a patient, it becomes conflicting to the provider on how to provide the proper “care” to each. Overall, the article adequately elaborated on the challenges young medical students take in addressing behavioral health histories and how providers must find ways to address these issues accordingly.

  50. When put into unfamiliar situations with patient, it is sometimes hard to get the ball rolling. As students we are taught to get information in a structured and formal way, but we sometimes forget that we need to break away from the format to get the information we need. Granted, it is important to make sure we gather all the information like past medical history and allergies, but sometimes in the moment we need to put those thing on the back burner and focus on connecting with our patients and helping with the issue they face. The patient is our number one priority and we cannot neglect giving them the proper care and compassion need at that time just because we do not know how to go about the situation.

  51. I think this article was a great way to enter into Behavioral Medicine. Although most students are aware it is important to make a personal connection with their patient, it sometimes becomes difficult when there is so much pressure to gather all the “important information”. This article is a good reminder to slow down, take your time, and focus on the patient’s problem at hand as well as their personal feelings. Building a personal relationship with the patient will allow them to trust you more and in the end tell you more about their story so you can give them better care.

  52. In medicine, especially as a student, it can be challenging at times to connect with patients on a personal level. I love how this article highlights the fact that patients are real people facing real struggles. As PA students and future providers, it can be so easy to focus on the medical illnesses and making sure we gather all of the pertinent parts of the patient’s history, but in the end it is just as important to talk with patient and hear them out. From this encounter, I can foresee that taking time to get personal with the patient will allow us to not only better understand them, but also to provide better medical care that they rightfully deserve.

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