Listening and Communicating

My approach to patient care has evolved over the years, with increasing experience as to how best to approach the management of people with neurological symptoms, and their families.

As is probably true for many of us when we first come out of training, my approach to care was initially relatively “transactional” meaning that my primary focus was on making a diagnosis and designing a treatment as expeditiously as possible.

Listening to my patient

Today, as my care style has matured, I try and focus first on what the patient, and their family, are most concerned about. I usually start a conversation by exploring what they think is wrong, and what they want to address during the visit. I ask a lot of questions about family, work, and everyday function, in part because these are usually “easy” questions and help the patient open up, and in part because I genuinely want to know about their life, and how the neurological symptoms are affecting it.

Building rapport

I use several strategies deliberately to build rapport quickly. One approach that I learned early in training from the master clinician and pediatric neurologist John Freeman, is to ensure that I’m sitting at the same physical height as the patient. This is especially important if the patient is in bed, and there are several providers with me in a group. I ask permission and sit on the bed, or pull up a stool to talk with the patient and then do the examination.

I also make sure that electronic distractions—cell phone or pager—are minimized during the interaction, and I make a point NOT to use the computer during the interview. If needed, I’ll take notes on paper, and maintain eye contact with the patient as much as possible. I use physical contact with the permission of the patient, for example touching the patient’s arm or hand. I find that this is a very effective way of focusing or calming an anxious patient, as well as reinforcing a point that I want to emphasize.

Another component of my care approach is to use the examination itself as a teaching moment, not only for trainees who might be with me during the visit, but also for the patient. I make a concerted effort to describe verbally what I am seeing on the examination in the second person so that the patient is included in the process, and gains information about what I am seeing and how to interpret signs.

Communicating with my patient

During the wrap-up to the visit, I make a conscious effort to go over the differential diagnosis in terms that the patient will understand, and use diagrams or pictures to explain what’s wrong, and then end with a discussion of what we’ll do to improve or treat the condition. In general, my delivery of news is optimistic, but realistic, focusing on the elements that we can change or remediate. If I don’t have a diagnosis, I state that clearly, and detail what I am going to do to enlist help from other colleagues or specialists.

Finally, I end the visit with detailed instructions for how the patient can contact me—all my patients get my cell phone number. I may give the patient “homework,” for example to start an exercise program, or look up certain results. I also stress what I’m going to do after the visit and when I’ll be back in touch with the patient. I make a point to send every patient my note, and follow up with a personal letter detailing test results, and most importantly, what their test results mean.