I haven’t spoken to as many patients compared to medical students at the other Clinical Schools, but I feel that I’ve spoken to enough to make some primitive observations. I have had reasonably positive experiences with most of the patients that I’ve spoken to, in that they’ve never been aggressive to me or abused me, however the accuracy and clarity of what they say varies, so in terms of medical content for collecting data, the quality varies. This is probably why a few nurses tell me that some patients are “better historians” than others.
Lack of Insight or Denial
Some patients are rather lacking in insight into their medical conditions. While I understand that they’re not doctors or nurses or necessarily have a background education in health, I would’ve thought that they know about a few aggravating factors or physiological mechanisms regarding their condition as the doctors explain to them (in a more layman manner, less jargon). I’m not sure if this phenomenon is more prevalent within the public hospital system, though I suspect it is.
A classmate and I met a patient who was being hospitalized for an increased frequency of tonic-clonic seizures and was already diagnosed with epilepsy several years ago. After he asked her about her history of presenting complaints, he then proceeded to ask routine questions. When asked about alcohol consumption, she said she drinks a slab of beer (24 cans/stubbies) every weekend. When asked if she felt that the beer might’ve been the cause of more frequent seizures (alcohol usually lowers seizure thresholds), she said “Nah, the beer’s alright.”This was despite taking into consideration numerous psychosocial factors, the doctors already informed her in a polite manner suited to her preferences of the great risks associated with binge drinking for someone with epilepsy.
Another patient that I saw with a classmate said he was diagnosed with hypertension when asked about other active health problems, but he claims that it’s because he has successful children (one of them a doctor), and that he leads a happy life which causes it. At the time I found this very hard to believe, seeing that his son has a medical background, and the patient himself also taught Science (biology/chemistry/physics) for numerous years, so should’ve understood the basic physiology of blood pressure. I thought it didn’t make sense to have hypertension from having a happy life, unless he happened to be using psychostimulants or certain antidepressants (especially MAOIs) every day. He also said he was diagnosed with Type II Diabetes, and he was overweight. By Occam’s Razor, it seems implausible that happiness alone causes high blood pressure; on the contrary it’d be more likely to be constant stress, poor diet that’s high in sodium or obesity. I checked his patient files. No surprise, he was diagnosed with Depression as well and was prescribed an SSRI antidepressant. At the time, I was quite annoyed coz I felt that he was deceiving me, but I spoke to other people about this issue, and they suggested that he may be feeling happier instead primarily due to the antidepressants, which allow him to be more euthymic and appreciate what he has in life (family). While he might not have understood the mechanism of antidepressants in making him happier, I felt that it was most likely that he was in true denial of the real causes of his hypertension, seeing that the SSRI he was on wasn’t supposed to significantly increase blood pressure.
For other patients, when I ask them if they have any other medical conditions, they say no, but their patient files state that they have hypertension, Type II Diabetes or hypercholesterolaemia. How a patient didn’t regard Type II Diabetes as a medical condition is beyond me, but I’ve been told by other people that Type II Diabetes has existed in many patients for 1 or more decades that they’ve grown accustomed to it, and no longer regard it as abnormal. This is why from now on, I always ask “Do you have high blood pressure/Diabetes/high cholesterol?” after asking “Do you have any other medical conditions” and them responding “No”.
At the time I’ve been very tempted to confront these patients and point out their misinterpretations or reduced insight into aggravating factors, but was told that this is the job of the doctors and nurses to do, not the Medical students. Therefore I’ve restrained myself from doing so, which is frustrating for me internally, but I’ve gradually accepted it as part of life, and decided to focus on learning more about their medical issues by reading their patient files, as opposed to just getting bitter and angry about it.
Asking Open-Ended Questions
I initially had the tendency to ask direct, specific questions to patients, but have been told that this may make the patients (majority NT) feel that they’re being judged subtly. They explained to me how certain direct questions can make patients feel that you’re judging them, but I felt that these impressions were excessive and I had no intention of judging/denigrating them, and that the patients are just being whiny and overly sensitive. After all, many NTs obsess about appearances and “keeping up with the Joneses”.
However after the first few weeks of Clinicals, I’ve realized the importance of asking open-ended questions. I know that it goes against my Aspie-trait of automatically focusing on details, and I originally thought that asking open-ended questions would mean that I’m “selling out” to conform to NT standards like a sheep, but I’ve realized the systematic usefulness of asking open-ended questions, which is probably the only Aspie-friendly excuse (to me) for using it.
For example, when asking about someone’s cigarette use, by asking “Have you ever smoked cigarettes?” at the start allows you to step into the topic broadly. If the patient says yes, then you can ask if they’re still smoking, when they quit smoking (if they quit already), and how much they smoke/day. If I had asked “How many cigarettes do you usually smoke per day?” as my first question, then I may have missed out on their previous history of smoking had they said “None”.
Therefore it is more systematic and easier to remember for some topics if I ask them from a broad/open-ended--> detailed fashion. I can then remember the flowchart of questions for that topic in a specific order. The questions are also ordered in a way to provide the least offensiveness and “judgmental impression” that is experienced by NT patients, so in fact a flowchart of questions from broad/open-ended --> detailed “Hits two birds with one stone” in that it appeals to both NT and ASD mindsets. Most NT patients wouldn’t be offended if you told them that you’re going to be asking routine questions, and then asked them if they’ve ever smoked cigarettes. However they might’ve felt judged if you asked “How many cigarettes do you usually smoke per day?” at the very start coz they feel that you assume that they smoke cigarettes, and especially if they have some sort of cancer (especially lung cancer), that the cigarettes are a contributing factor to their medical condition, and that the question is too confronting as it addresses their “fault” in smoking, hence making them feel guilty/bad as well.
My example for smoking history is below (click on picture for enlarged version):
I was lucky in that I managed to follow this flowchart for smoking (and a similar one for alcohol) after a few weeks. It was initially surprising to me when I learnt about other sensitive psychosocial factors that can be mentioned/triggered when I perform the history for both.
Soon after I followed this flowchart, I spoke to 2 patients.
For 1 patient, when I asked an elderly woman “have you ever smoked cigarettes?”, she said she used to smoke when she lived with her husband, and then she quit to make her husband happy, and then she started again after her husband died, and she started crying.
I felt awkward and sorry for her. Admittedly I didn’t know the direct cause of her crying. I couldn’t tell if she was crying coz she started smoking again, or coz her husband died. An (NT) teacher who was sitting down and observing my interaction with her said that it was due to the latter (husband died), and that asking the smoking question reminded her of her husband’s death. I was so surprised that asking an open-ended question could’ve released so much info from her, but she may have been an exception due to specific familial circumstances that happened to have smoking intertwined with it.
I then remembered the ICM video about what to do when a patient cries: you’re supposed to stay quiet and maintain a pause for at least 10 seconds while handing a tissue box to them to take a tissue to wipe their tears. I did that, and the patient said thank you. The teacher then asked her if she was alright with continuing the conversation, and she said yes. And so the interview proceeded.
The other patient I spoke to on another day, I later asked “have you ever drank alcohol?” and she said “Never in my life!!!” She then said that she grew up in a household where her Dad was an alcoholic, and would be abusive to her, her siblings and her mum. She had a traumatic childhood and to this day never drank alcohol. She said that she finds it very upsetting and judgmental when other doctors ask her “How much alcohol do you drink?” because they automatically assumed that her liver cirrhosis was due to alcoholism and that it reminded her of her abusive Dad, when in reality there must’ve been some other aetiology to it. She was actually kinda upset that I asked that question, but the teacher (who watched my interaction again) did tell her that I stated it was a routine question and that it wasn’t meant to judge her. She later calmed down and proceeded with the interview.
I think after these 2 incidents, it really “hammered” it in that if I had asked the direct/detailed questions first instead of the open-ended ones (according to the flowchart), I would’ve gotten into deep shit or created a lot of friction/tension with the patients.
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