The Closer

DB over at DB's Medical Rants is trying to come up with a curriculum of essential bedside clinical skills.  Of the many skills I learned after I started practice, closing the interview is probably the most important.  In rheumatology we often make the diagnosis at the first visit because in our specialty, history and physical rules. A classic example would be a new rheumatoid arthritis patient with multiple swollen joints in a classic distribution.  Early in my career I would make the diagnosis,  pass on my opinion to the patient with a brief course on the natural history of the disease and a treatment plan.  The protocol was fairly standardized and efficient but the results disconcertingly  variable.  Some patients would leave the room with the bouncy gait of renewed optimism that I had hoped to instill, while others left no less anxious than when they came in, others worse.  What I've learned since is that patients come in with a lot of baggage and a diagnosis alone doesn't always lessen the burden.  You have to find where the patient is coming from and try to unload the old stuff while addressing the new.  I was surprised to find that many patients with RA believe they have another more serious disease.  Interestingly, my french patients seem to have a morbid fear of multiple sclerosis, and my english patients tend more to 'bone cancer".  When you tell these patients they have rheumatoid arthritis, that doesn't necessarily take these possibilities out of the picture.  I will now often tell patients directly that they have no cancer or MS, but RA, a treatable disease .

  RA is also a common disease  with a hereditary component so there is a fair chance that the new patient will know somebody who had the disease, often years ago, in the days when there was no effective treatment.  These pre-methotrexate patients suffered horribly and deformed relentlessly.  They became cushingoid because of the corticosteroid treament that was the only thing that gave any relief and then they died, the death more often than not attributed to 'the cortisone'.  So when I come along and tell them that they have RA and will start them on a small dose of prednisone while I get them on a remittive agent, what they actually hear is CORTISONE!  It's important to find out where the patient is coming from and address those concerns. 

 A clinician also has to stay in the present.  When I see a new RA patient I feel pretty confident that I will get it under control in the near future.  Since the arrival of the biologic meds I feel almost cocky about my treatment options.  I'm not worried.  That's all great but the patient still has hugely swollen joints today and can't see much beyond trying to get out of the too-deep chair that I have in my office. Address today and tomorrow and then we can talk about the coming months and years.

Doctor-patient communication.  I'm sure that's what most will comment about on DB's blog.  Just remember, for the internal medicine clinician, making the diagnosis is just a good place to start.  

Comments

[Krys]

You wrote that " What I've learned since is that patients come in with a lot of baggage and a diagnosis alone doesn't always lessen the burden." This is especially true today with the unlimited opportunities the Internet offers for self-(MIS)-diagnosis -- the possibilities for acquiring serious baggage in the form of rare,little known, but severely debilitating (or even fatal) conditions are limitless. Google is not necessarily one's friend.

[3+speckled]

There's medical stuff on the internet?