Starting the Encounter

The first moments of a clinical encounter set the tone for the entire visit. Knock before entering a patient’s room and ask their permission to come in. Start by introducing yourself by name and role and confirm your patient’s identity with their full name. Everyone new to the patient, from lab techs to nurses, takes this key patient safety step.

MS1: Hi, Im Janice Allen, a first year medical student. Are you Jamie Smith?

Patient: “Yes, I’m Jamie. Nice to meet you”

Next, ask an open-ended question about how the patient would like to be addressed. They may prefer to be addressed formally (Mr. Smith) or informally (Jamie), or they may share a name different from the one in their medical records.

MS1: “Nice to meet you too. How would you like me to address you?”

Patient: Jamie is fine.

If your patient has not suggested that you address them with a gendered title (like Mr. or Ms.) you can avoid mis-gendering them by following up with a phrase like those below.

MS1: “I use she/her pronouns. Which pronouns do you use?” OR

MS1: Could you confirm your gender and age for me? OR

MS1: “If I refer to you by a title, like ‘Dr.’, ‘Ms.’, or ‘Mr.’ which should I use?” OR

MS1: “Throughout my notes and in discussions with my colleagues, do you have a preference of how you would like to be addressed?”

Once you’ve confirmed your patient’s identity, greet any guests in the room and ensure you know their relationship to the patient. Before starting the history, confirm that it’s ok with the patient for them to be present.

Setting the agenda

Agenda setting is important in both the clinic and in hospital tutorials. In the clinic, setting an agenda takes only a minute or two, and both improves efficiency and empowers patients. This is an important skill, and we’ll spend more time on it before you start in your primary care clinic.

  1. Indicate the time available. “We have about 20 minutes together today.”
  2. Forecast what you would like to have happen. “I know you want to talk about the shoulder pain you’ve been having, and I want to follow up on your blood pressure.”
  3. Elicit other concerns that your patient would like to discuss. “What else would you like to discuss today?
  4. Confirm the list of concerns and screen for other issues, like need for medication refills, forms filled, etc.
  5. Decide together how to spend the visit, taking into consideration the patient and physician needs.

For hospital tutorials, the process will look a little different but you should still set an agenda to orient your patient to the interview process.

  1. Indicate the time available. “I have about an hour and a half to spend with you.”
  2. Forecast what you would like to have happen. “I’d like to hear about the shortness of breath that brought you in to the hospital, then get a complete picture of your health history and perform an exam of your head and neck, heart, lungs, abdomen, nerves and muscles. Does that sound ok?”
  3. Elicit other concerns. “Is there anything else happening this morning? Tests or consultations? Anything else I should know?”

Discussing confidentiality

For hospital tutorials, before continuing on, take a moment to let your patient know that we are not part of their healthcare team. We will not share their information with the people taking care of them or writing in their chart. The only exception is if they are thinking of harming themselves or someone else. That information would be shared immediately with their healthcare team. Should a patient ever report this to you, discuss it with your mentor immediately.

“I’m not part of your team, and I won’t share any information with your team or in your medical record. The only exception is if you tell me that you are considering harming yourself or someone else – I would need to tell your doctor about that.”

You will share what you’ve learned from your patient with your teacher and your small group. With your patient’s permission, you’ll return to the bedside as a group for bedside teaching.

Confirming consent

This can be simple – just ask your patient if all of this sounds ok. Your mentors and patient interview coordinators have already gone through a more formal process of describing what will happen and obtaining each patient’s consent. If your patient expresses reluctance or has concerns, check in with your mentor on how to proceed.

License

The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.