By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Key Feature 1: In all patients presenting with multiple medical concerns (ex: complaints, problems, diagnoses), take an appropriate history to determine the primary reason for the consultation.
Skill: Selectivity, Clinical Reasoning
Key Feature 2: In all patients presenting with multiple medical concerns, prioritise problems appropriately to develop an agenda that both you and the patient can agree upon (i.e., determine common ground).
Skill: Patient Centered
If you're a physician working in any area of medicine - and I would say particularly so if you're a family physician - you frequently have patients present to an appointment for multiple medical concerns. If you're a physician on a schedule (like, who isn't?) who doesn't have an hour time-slot to comprehensively address the sometimes multiple presenting concerns, prioritising is important to address the most pressing issues. The script that I've found works for this when I start a patient encounter is as follows:
1. Wash my hands before entering the patient environment (10 points)
2. Introduce myself (Say my name name and that I am a resident working with the physician)
3. Clarify their identity (Confirm their name and how they would like me to address them [ex: If their name is Jennifer, I ask if it's okay that I call them Jennifer or if they have another preference, such as Jen] if I think it's warranted)
4. At this point I like to say something to build rapport, such as apologising if they had to wait to be seen, or complimenting them on something nice they're wearing. If they look somewhat uncomfortable I use this moment to see if there's something I can do to make them more comfortable. This is just a nice thing to do, but it also seems to promote patient agreement to have me lead the appointment (see next point)
5. State my intent (Not everyone knows what the role of a resident is, so I say something along the lines of "As a resident, I'm a doctor who has recently graduated from medical school and am training to be a family doctor. If it's alright with you I would really appreciate if I could work through what brought you in to the clinic today and see if we can come up with a plan to address it together. I would then review with my attending physician to make sure they're on board with the plan and to see if they have any further or alternative suggestions. Is this okay with you?
6. Elicit presenting concern(s) ("So what brings you in to clinic today?" They may say one concern and only have one concern, they may say one concern and have multiple concerns, or they may say multiple concerns right off the top. So I hunt further. "And is there anything else that you were wanting to address today?" I repeat, "Anything else?" until they have run out of concerns.)
7. Prioritise (Unnecessary if a patient has only one concern, but this tends to be the exception in the family physician office setting. I start off by asking them, "Out of the concerns you currently have, which of these is most important for you that we address today?" If I've elicited a concern that I feel could be a more urgent issue [ex: chest pain], then I will let them know it is of greater concern to me. This may in fact change a patient's priorities, because if the doctor is more concerned about one thing than another, then the patient sometimes also perceive it as more medically important to work up first. I ask if this is the case, "Knowing this, would you be okay if today we addressed the issue I think is more medically urgent?" If they are not, I then go on to address the patient's greatest concern, but still briefly rule out any acutely worrisome features of the concern I am most worried about and ask if they can book a followup appointment in the next day or so, assuming there is nothing identified as seriously urgent compelling action at this visit. In reality, the agenda tends to be a compromise, such that multiple concerns are in fact addressed at the visit, and that followup visits are also warranted. I explain that to do a thorough job addressing each concern, I really do need to be able to devote more time to working each one up. Patients tend to be agreeable to this.)
Prioritising the appointment agenda is a great example to me of how the art and science of medicine collide. Although I've been trying to hone this part of the patient encounter for the past 4.5 years now (medical school and now halfway into my first year of residency), I am still constantly tweaking and adapting my approach. There is no one-size-fits-all-patients approach, and creating an agenda that the patient and myself can agree on, and to do so efficiently, is a work in progress. Finding the common ground between patients' value-informed concerns and my own hierarchy of most important medical concerns is one of the most frequent challenges in the family physician office visit, but without devoting the time and energy to doing this well at the start of the visit, this can lead to serious disappointment for me and the patient. The patient may otherwise only mention a potentially serious medical concern (something that cannot be ignored) at the end of a visit, requiring time to address that may make the next patient's appointment start late. Or the patient may be disappointed that the reason that was most important to them that they wanted to come in for wasn't addressed. This can happen if they mention a secondary concern first (sometimes there is some fear about discussing certain problems, perhaps related to stigma or fear that a symptom is indicative of a serious underlying medical concern) and we've taken the full appointment time already to address the less concerning issue in full.
As a family physician, both the selection of appropriate medical interventions and the quality of the patient-physician encounter are important in providing high quality primary care, and establishing a mutually agreeable agenda at the start of the office visit is, in my opinion, a requisite for this.