Dr. Alberto J Muniagurria
Dra. Mónica Espinoza
The Medical Consultation or Interview is the fundamental act of the professional activity of the doctor. This takes place in a space known as an office , in the outpatient activity, but can be carried out in a room of a Sanatorium or Hospital, in hospitalized patients, or at home, when the consultation is started in that space.
It is in this interview where the knowledge of the patient's health and disease history is built, and where the Clinical History is recorded. It is where the doctor's relationship with the patient is developed and the order of the clinical method is followed, that is, where subjective and objective data, both clinical and complementary methods, are obtained and the List of Problems is prepared.
It can be understood through a metaphor that the interview or medical consultation is an agreed meeting between 2 actors, a medical professional and a patient, to assess the health / illness status of the patient, in a scenario, called an office, with a script , known as Clinical History, and that the information obtained is different (variable) in each of the interpretations.
The variation is given by the reasons for the query and the uniqueness of the consultant.
The doctor-patient relationship will develop over time, largely, depending on the doctor's professional attitude, his empathy, but also the patient's attitude that comes in the search for knowledge and how it happens in every human relationship, with the necessary confidence deposited. In any case, there must always be a relationship of respect for both parties.
The place and circumstances where the medical interview takes place, in the case of the Office, must be adequate. It is necessary to have a degree of comfort (a suitable place to meet the patient), privacy , silence , lighting and temperature.
It is convenient, before starting the meeting, to evaluate if there are previous patient data so that when entering the office, they are taken into account. Observe the order of the office or healthcare space, remembering that each new consultation is a new start of bond. The order allows to be more efficient and effective.
It is a requirement in the interview that the doctor knows how to listen carefully, use silence on time, avoid sermons, take into account the socio-cultural and religious characteristics of the patient, as well as transmit security, serenity and poise.
The interview begins, generally through an appointment previously requested by phone, Internet or in person. The attitude of the staff who treats him, as well as his diligence and efficiency, will be evaluated by the patient. This already generates an element of importance, to take into account. Respect for schedules. You should never wait more than 15 to 20 minutes, the patient on duty. It is also important to highlight the respect for the schedule on the part of the patient since in some way it shows the interest in the consultation and the consequent adherence to a treatment. Another point to take into account is the degree of hygiene with which it occurs, in cases where these conditions are possible and according to the level of its possibilities.
The role of the two actors, doctor or patient, may vary with the type of query raised.
If you are facing an acute illness (acute abdomen, digestive hemorrhage, cardiac arrest) the protagonist of this interview should be the treating doctor, since in these situations the indications are accurate without giving much room for delay. Times do not allow negotiation since in many cases that means life or death.
On the other hand, if you are facing a consultation for a chronic disease (obesity is the quintessential example), the main protagonist in this interview is the patient since the stricter the indications the less adherence they will have to the proposed indications since the negotiation it is the fundamental base in these treatments. Here the proposal is to propose a feasible treatment, possible to be respected and sustainable in the long term. Proposing only sustainable treatments for short periods of time in chronic diseases will appear in the future, among the curiosities of medicine.
No less important is the role played by the family in the interview, since in many cases it is a presence that enriches by providing data that the patient does not know or does not remember, especially in pediatric patients, and in other cases, deteriorating the doctor-patient relationship.
Thinking of other places or models of consultation, the doctor not only has to evaluate the different circumstances described above, but also the role played by his presence in interviews with friends or family where familiarity often makes it difficult to comply with the indications.
If you consider the communication model, it can be said that in the Spanish language there is the treatment of you to the unknown person. But this is not definitive, and it should be used according to the circumstance, given by the age, gender, attitude, personality of the patient and also of the personality of the doctor and the circumstances in which he is seeing the patient, etc. . Remember that you. It marks a distance that should not be lost from the beginning. There are many people who prefer it. The treatment must always be respectful, although adjusted to the circumstances. With children or familiar people a more informal treatment is better. Sometimes it may be appropriate to adopt a more "paternalistic" attitude, at other times a more formal relationship is better, which can even progress to a more informal treatment if it arises spontaneously. In general terms, it is suggested to avoid colloquial affective terms such as darling, chubby, etc., etc.
When the door is opened, the doctor begins to study the patient, observing his attitude, dress, body language, etc., etc. At first you should extend your hand to say hello , and say " Good morning", good afternoon, or How's it going? To immediately offer a seat. If you consider it necessary, you can say, once you are seated: It is observed that you are in trouble, I hope I can help you.
The medical dialogue can begin with : Why are you coming to see me? , or What is the reason for your inquiry? Initially, the patient should be allowed to speak by listening carefully, if possible without interruption, except for clarification. Interruptions with questions can divert the patient from her fundamental objective, or make her forget and then say it out of time (last minute problems). In general, the patient does not take much more than 2 minutes to express his reason for consultation. At the end of your first presentation, you may be asked: What other reason are you concerned about? Once this is answered, the doctor can make a summary of the exposed to evaluate the agreement of the patient.
Immediately the directed interrogation begins , where a question is reelected to order the information.
Sometimes the patient consults for multiple problems and this makes time management difficult. In this case it is not out of place to circumscribe the dialogue for what is most acute or important for the patient such as pain or fever or the same health check-up, leaving for another interview chronic problems such as constipation or diets for example. Involve the patient in the decision of the time to use that obviously has to have a limit.
When entering the directed questioning, the collaboration of the patient should be sought by explaining the reasons for certain questions, and avoiding information that does not ask the question, which is generally expressed in the use and abuse of qualifying adjectives or transmission of emotional aspects. The patient's gaze on the data is very useful and must be taken into account. By listening, the doctor is using his intelligence and memory to build the Problems.
The use of open as well as closed questions serves to understand situations. Saying " Tell me" openly generates more information than closed questions like "Tell me about the irradiation of your pain" , which demand a specific answer. The open question predisposes to a more spontaneous relationship, which can then be refined in progressive dialogue. Once the open question is answered, one or two closed questions are asked to complete the information. Once the information has been obtained as to what data is involved in the consultation, it is reasonable to delve into specific or closed questions about them.
In order to get to know the patient, it is important to observe them in detail, thus obtaining information on their languages, speech or discourse, gestures, dress habits, prolixity, degree of hygiene, ethnicity, cultural level, gestures, sense of humor, attitude , timia, religion, importance or hierarchy of the data and how they affect it.
The active, attentive attitude of the professional acquires importance . This means being attentive to perceive the metaphors in the speech, the framing of the answers or spontaneous information, beliefs ( Thank God ... ), tone of voice, what is not said and expressed with the hands and the body, what it is suggested, the relationships in their environment, their affections, etc., etc.
The opinion of the patient on their problems, as well as that of their environment, becomes important (the presence of a medical relative is frequent). Try not to separate the socio-affective information that is obtained from the strictly medical, since this improves the bond and the relationship.
Always give the opportunity to add information about the query or any other question that arises. In repeated circumstances the patient wants to internalize the reason for his symptoms.
Once the information collection is completed, it is very important to carry out a complete physical examination in the first consultation, and to repeat some maneuvers in successive consultations.
In the physical examination it is important to respect certain principles such as:
- Respect the patient's modesty
- Be delicate in the maneuvers
- Have available the elements or instruments necessary for the examination (gloves, ophthalmoscope, otoscope, stethoscope, hammer, etc. and take care of their temperature.
- Bacteriological isolation such as hand washing and wearing the dust cover at all times and wearing masks in some cases.
Once the information of which data is involved in the consultation has been obtained, it is reasonable to delve into specific or closed questions about them.
Changes can always appear in the findings, and the contact developed through the examination is highly valued by patients in general, inspires and transmits the feeling of professionalism, knowledge and dedication to the search for information. A stethoscope on the chest mobilizes a stream of respect and commitment to your doctor. The reason for practices should always be explained to the patient, especially those that are invasive, such as rectal or gynecological examinations. In case of maneuvers that generate pain, do it gently and explain it. Do not go directly to the pain area, progressively approach. Likewise, if it is interesting, for example, the right side of one area of the body to start with the other, left, which is supposed to be normal.
Finally, doctors must provide information to the patient regarding their consultation and the findings of the examination performed. Time should be devoted to educating the patient with information on the studies requested, possible diagnoses, and eventually prognoses.
It is important that this information is clear and honest, and prudent. In those cases in which they have a poor prognosis, although the patient must know what he has, it is not necessary to communicate everything in one session, " like a bucket of cold water ." There are different ways to deliver the information, and eventually, you can prepare the person in different interviews. It is convenient to work these situations together with the family, but respecting the privacy of the patient.
It is very useful to give written indications, for various reasons, including serving as a reminder for the patient, and prolonging the prominence of the indication.
It is important to take care of the comments about other colleagues who have participated in the care. Given the disagreement with some measures taken by them, use silence rather than the denigrating word. Remember that reality is different at different times and circumstances. It is easy to know the result of the race with the newspaper on Monday.
In the rapid evolution of time, it is possible to imagine a day when patients will be interviewed by computers, which will quickly measure the sensitivity and specificity of the data provided, suggesting appropriate interventions. Those computers will replace doctors with an efficiency that the computers themselves will be able to evaluate.
If this is possible, the challenge is to develop programs that transmit compassion , affection, protection, humanism, vocation, companionship in suffering, or all that is professionalism through spoken and corporal language in the Doctor-Patient relationship.
Perhaps if it is possible to meet this challenge, this will be as pleasing as a plastic flower with artificial perfume.