Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Reading Your Patient and Changing Your Plan


We usually already have an agenda set when we see patients. However, we have to be ready to improvise by reading the patient, and be open to changing our plan.

Reading my patient’s vibes
My 60-year-old patient was withdrawn and pensive as he sat down. Normally very outgoing, he started our conversation with, “I’m feeling so stressed.” He related how he was now raising a four-year-old cousin whose mother had died from an overdose and whose father was now incarcerated. “I’m too old to be a dad again.” The child was a challenge.

“Last night, he locked himself in the bathroom and wouldn’t let me in. When he finally did, I found him with a crumbled piece of cookie on a plate. I asked him what he was doing and he replied, ‘I’m making my next fix like my mommy did.’”

His vibes told me he didn’t want to talk about glucose control, or losing the five pounds he had set as a goal last visit. He cried and I responded with silence and a tissue.

Addiction—a family disease
Addiction has always been a family disease, spreading its powerful reach even to those not using drugs. In 2016, about 60,000 Americans died of an opioid overdose, with many more than that incarcerated for a disease as well. There’s no accurate way to determine the number of children impacted, many orphaned, some placed in homes by child protective services, and many arriving in homes of family members thrust into the role of parent, like my patient.

The impact on families is even harder to assess. Raising a child late in life brings unforeseen financial burdens for which patients may make undesired trade-offs—buying things for a child rather than paying the co-pay for a needed prescription.

Therapeutic listening
We spent his entire visit talking. “My family always views me as the strong one. That’s why they asked me to take John in—I was told I could handle him.”

I’m seeing him back in two weeks—maybe he’ll be ready to talk about his glucose and weight. I know that at some point, the visit focus will become the need for him to take care of himself in order to care for John.

We usually have an agenda already set for the visit when we see patients. However, we have to be ready to improvise, by reading the patient, and just like a football quarterback, call an audible, and change the play/plan. Therapeutic listening builds rapport and will help in connecting on future goals, such as weight loss and better glucose control.