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Engaged Patients Make Better Patients

Reflecting on a couple of tough cases I’ve had myself and my girlfriend, who is a rheumatologist, complex cases don’t require complex thinking or complicated workups.

It’s Sunday, and you decide to review your patient cases for Monday. 93 yo with recent hospital discharge for sepsis and partial pneumonectomy and a drain in place. WTF.

There is the 58 yo woman with ongoing fatigue, forgetfulness, weight gain, poor sleep, and migrating arthralgia. She’s been seen by 10.5 doctors and is coming to your for “seeking diagnosis for ongoing sxs.”

Patients Want to Be Heard

I remember the exact time when I first learned the important of feeling heard. I had this weird tooth pain that my own dentist couldn’t figure out. He was really good at what he did. He sent me to an endodontist for a better eval.

When I got there I was so anxious to tell her the entire story (because it was complicated) before having her interrupt me. She let me talk as long as I wanted and just let me talk and asked for clarification. I felt so light afterwards, like I got everything out.

People have practiced telling you what’s going on for days. And when they get there, sometimes they have senior moments and feel deflated. But when you let them talk, explain, and even vent their frustrations, they feel good; they feel heard.

People who feel heard rarely get angry; even the crackheads on my street here in Long Beach, if I let them really yell at me, really get everything out that they need to, they seem much more relieved.

Ask Good Questions

Remember when you flushed too many tampons down the toilet and the plumber came out because your bathtub wasn’t training? If they didn’t ask you about the tampons or the toy T-Rex your son flushed down along with the goldfish, you would have never put 2 and 2 together.

Spending time listening means you’ll also have great questions to ask. A great question helps the patient think deeply about their condition and uncovers valuable information that you can use for your workup.

You don’t have to be smart to ask great questions. My grandma used to, and she wasn’t a doctor. You just have to be present, listen, and be genuinely inquisitive.

Asking great questions takes time, patience, and leaves both parties quite content. But if you don’t ask the important questions then the patient will keep repeating themselves and you’ll sit there wondering “WTF! I just answered this mofo and he’s still asking the same thing?!”

Did you come in today because you were worried about something more serious? Oh, I see, your mom had cancer and she had similar symptoms and it got brushed off by her doctors. Let’s talk a little more about ovarian cancer together and see if we can rule that out.

Follow Up With Them

On a given day, most of my patients just want a quick diagnosis, a quick antibiotic, a referral, or an MRI ordered, and they are happy.

Every 5th patient, or so, has something more complex. They aren’t in my clinic for a verbal hug; they actually have something more complex and worrisome going on.

Fortunately, even the worrisome things end up being nothing. 1.5 yo with super high fevers and a crazy rash? 2 days later, they are back to digging poop out of their diapers as if nothing happened.

But I would never know if I didn’t call those patients back and follow up. I have my own method these days for following up. It involves me calling them or leaving a VM. It’s always quite appreciated, and only 10% of the time do I get caught up in too long of a conversation, immediately regretting why the hell I call patients back in the first place.

Empower Them To Make Them More Engaged

The empowered patient won’t sit at home with a massively infected post-op knee, wondering why the doctor never follows up with them.

Dr: But, ma’am, at no point were you worried abotu the super high fevers, the massive, red swelling on the knee or the fact that you couldn’t put any weight on it?

Pt: Well, nobody told me that was bad. And my doctor never called so how would I have known!

To empower a patient I need to give them lots of resources, such as what to do if xyz happens. They should know what they can do for themselves if shit hits the fan: go to the ER, call my office, go to the urgent care, or call a telemedicine doctor for guidance.

Patients only feel empowered when they feel they have control over their health outcomes. If they feel that you are taking over all the power and they are left feeling powerless, then they’ll be the needy stepchild who can’t even microwave a damn tortilla.

An engaged patient will speak up for himself and give you healthy pushback. For the love of god, if someone gives you pushback, welcome it! Don’t shut the patient down; that’s their way of checking you on your shit.

I had a patient tell me off, this 24 yo woman sitting in a wheelchair because the pain behind her knee was driving her crazy. After 3 other doctor visits, I was about to brush her off, too. She basically had to force me to get her an MRI, and sure enough, she had a mass growing there.

Think Out Loud

I learned a good habit from other experts, which has worked wonders for me—or so I think. I think out loud, kind of like I’m talking to myself.

When I owned a mechanic shop, my lead mechanic would walk around under the car with his tools and this metal-tipped stethoscope, talk out loud, and explain what he was doing. It was brilliant.

Okay, so here we go, it looks like there is some instablity of the knee when I move it this way which could be ligament or just a lot of fluid in there.

Nice, I don’t feel any masses in the back and the skin doesn’t look red so I’m not really worried about an infection.

Now, let’s have you stand up and walk so I can see if there is any instability when you’re weightbearing. Okay, great, looks like you can do a half-sqaut and pivot without the knee giving out which tells me that it’s not a terrible injury.

Next, I want to get the MRI because I need to make sure you don’t have a major tear of the meniscus since that would make you a cnadidate for surgery – not that you’d have to have it but something we should consider.

When you think out loud, you are educating, offering follow-up, consenting, guiding, and advising the patient all-in-one. It’s the best use of my ATPs and breath in the exam room that I can think of.

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