If doctor visit goes badly, try a restart

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IN PRACTICE
If doctor visit goes badly, try a restart

Maybe the physician was distracted. Or spoke too quickly. Whatever the communication problem, take a deep breath and try again. Sometimes doctor and patient benefit from a second take.

By Lony C. Castro
February 16, 2009 in print edition F-3

It was a gray winter day, and I was running behind schedule. I still had Christmas shopping to do and was hoping to get out of the clinic before 6 p.m. The prospect of cold and dark skies on the way home wasn’t appealing, and I just wanted the rest of the day to go smoothly.

My next patient’s case appeared to be straightforward. She had been referred to me because of an abnormal alpha-feto protein test (a blood test used to screen for certain birth defects such as spina bifida or Down syndrome). The encounter would involve counseling, a detailed ultrasound to look for fetal or placental abnormalities, and possibly an amniocentesis. The latter test requires the insertion of a needle into the amniotic sac. As a maternal fetal medicine specialist, I knew that patients worried about the possibility of a fetal abnormality, such as Down syndrome, but also about the amniocentesis procedure. They worried about the potential pain and complications, as well as the subsequent decisions they would face if the amnio or ultrasound were abnormal. Would they continue the pregnancy? Would they terminate it?

The time of year, when many patients were trying to focus on the holidays, seemed to heighten the anxiety.

Cold response

I walked into the room briskly and with a smile: “Hello, I’m Dr. Castro. I’m the perinatologist, and I will be doing the ultrasound and the amniocentesis if you decide to have it.” Immediately, the room seemed to grow cold. The patient and her husband stared at me. I proceeded to explain the potential reasons for an “abnormal AFP test,” the sequence of evaluation and the benefits and risks of an amniocentesis. I spoke fairly rapidly with quite a bit of detail, and the room seemed to grow colder. “Is there anything I have said you don’t understand?” I asked. The couple looked angry now. I sighed. Something had gone wrong and it wasn’t getting better. Were they angry because they waited too long? Did I explain too much too quickly? Did I offend their religious beliefs? I thought for a moment. I wished I could just start the whole encounter over again. Then it occurred to me – why not?

I looked at the patient and her husband. “I’m sorry, I feel as if you are both upset by something I did or said, but to do the best I can for you and your baby, we need to trust each other. So, if you don’t mind, can we start over?” A glimmer of a smile appeared on the patient’s face. “Yes,” she said.

I briefly left the room.

Outside the door, I inhaled deeply. I forgot about being late, forgot about the weather, forgot about Christmas shopping and just thought of the patient and her problem. I re-entered and reintroduced myself. “Hi, I’m Dr. Castro and I am sorry to have kept you waiting. You were referred to me because your blood test showed an increased risk of Down syndrome.”

‘Worth the wait’

I then explained what a screening test was and that, although the test indicated their fetus had about a 1 in 100 chance of having Down syndrome, many of these tests were “false positives.” There was a good chance the baby would be unaffected. I spoke slowly to make sure the patient and her husband could ask questions. The cold stares disappeared, and the couple began to take part in the discussion. They assented to the ultrasound (which did not show any evidence of physical anomalies), but declined the amniocentesis. When the patient left, she gave me a grateful smile. “Thank you,” she said, “we were so worried, we didn’t understand this test at all and now we do. The time you spent with us made it worth the wait.”

I remember this encounter often. It re-taught me several principles of physician-patient interactions and communication – principles that I already knew but did not always put into practice. It reminded me, first and foremost, not to let external distractions interfere with my rapport with the patient, to apologize if a patient is kept waiting and, if I don’t seem to be connecting positively, to slow down and try another approach.

But the major reason I remember this encounter is that it taught me a completely new approach, one that I had never observed while in medical school or during my residency. I learned it is OK to tell a patient that you recognize that the encounter is not going well and that you can, with the patient’s permission, start over.

Castro is a professor and chairwoman of the obstetrics and gynecology department at Western University of Health Sciences. lcastro@western.edu

http://articles.latimes.com/2009/02/16/features/he-inpractice16