Two months into medical school, I finally feel less like an impostor when I put on my white coat each week for an afternoon at the hospital. While it is still uncomfortable to interview patients without fully understanding the pathophysiology of their afflictions or being able to provide care, I have accepted the educational value of the exercise. With some additional imagination, I can even conjure up a benefit to the patients whom I interview: most of them have been at the hospital for a while, their days rendered monotonous. Perhaps talking with someone whose primary skill is listening and who can spend more than a few minutes at their beside gives them something to do, a chance to tell their story. Perhaps there is even a little therapeutic value in that—doesn’t everyone like to tell their story?
Ms. B certainly did not. Soft spoken by nature, she was on pain medication after her hip replacement, causing her to slur her speech and making conversation difficult. Ms. B dozed off numerous times during our interview but tried hard to stay awake, my guilt at keeping her up compounding with each episode of somnolence. I periodically looked over to my supervising preceptor, searching for the slightest indication that it was reasonable to abort the interview. Alas, no indication. And so we inched forward, me asking a question or two and her answering as best as she could before nodding off. Rinse and repeat.
I still do not know how to be efficient at obtaining a medical history while putting my patients at ease. I inevitably err on the side of the latter, taking conversational detours in order to not come across as curt. My interview with Ms. B is a fitting example: I likely could have elicited more medical information from her if I had been more determined in waking her up. While her periods of sleep never lasted for more than a few seconds, they disoriented her, compelling me to repeat my questions. How might I have been able to keep the conversation going without making her even more uncomfortable? I certainly would not have wanted to raise my voice; perhaps I could have tried to gently touch her hand whenever she nodded off?
Much later in our conversation, Ms. B revealed that the “accident” she had been referring to for the first twenty minutes was a fall caused by a heroin overdose in her fiancé's kitchen many years ago. She seemed comfortable sharing this information, but wanted assurance that it be kept confidential; she also made very clear that she was not in the habit of sharing her substance use history with her doctors. I do not know why she chose to talk about it in our interview. Part of me cannot help but think that I helped put her at ease by being respectful of her need to take the conversation slow and by expressing empathy toward her hip pain and her story. There is no way for me to know, and perhaps I am just rationalizing my decision not to be more assertive.
I am still learning how to navigate the tradeoff between gleaning medical information and putting the patient at ease, as both are essential for proper, patient-centered care. Knowing that the histories I obtain at this stage of my training are purely for practice and irrelevant to treatment decisions makes it easier to put patient comfort first. However, soon the stakes will be higher and the tradeoff will be murkier: information is key, but could be witheld if the patient does not feel comfortable; yet time is limited, and every additional minute spent taking the history is one less minute for the physical exam or treatment. Ultimately, I hope that practice will teach me how to walk this line in a manner appropriate for the clinical context and the patient in front of me. Until then, I will experiment with different questions and pay close attention to my patients’ reactions.
Identifying details have been changed.