She sat and stared, entranced and scared, into nowhere.  Her  knobbly knees pulled up obtusely by her spindly arms, cradled by her sullen face.  Dark eyes, but compliant and waiting.  I called her by name, and an automated, shuffling gait arrived her in quiet into my room.  

There was no response to my introduction other than an avoidant gaze and a stuttering mumble.  She resumed her former posture on the consulting room chair that looked somewhat oversized for her frame.
The notes from her psychiatrist read ‘complex PTSD, not eating, please sort’. Easy, peasy….Hmmm.
New patient – how to establish rapport with a virtually non-communicative patient?
Therein is the art of our profession. 
Simple and non-confronting questions. Empathy, affirmment, and lots of reading and relating of non-verbal cues.  And waiting – it takes some bravery to sit in silence with a patient but we underestimate how empowering our humility and ‘just listening’ can be.
But slowly the mumbling formed words, and then short sentences, with an audible volume, although punctuated by a stutter. With time the stutter was replaced by a longer string of vocabulary accompanied by a tighter embrace of hands around her knees.  Then, after much time, the admission of starving and purging as a form of punishment came, never disclosed to her long term psychologist.  And finally, a plea to feel well and healthy, accompanied by the phrase:

‘A doctor has never said so little to stop my stutter and let me explain’. 

As GPs we underestimate the power of just ‘being’ for our patients.   A Spanish Inquisition and fancy tests are often for our own reassurance rather than for the patient’s benefit.  In this case, no tests would have revealed the diagnosis, only useful to assess severity and complications. The patient’s words, if we choose to facilitate hearing them, can be diagnostic, and can serve to mitigate our uncertainty faster and better than any test.
We should revel in the luxury of listening.  
The temptation to funnel the history-taking, examine, investigate, and intervene was there from the minute I saw this young lady’s posture in the waiting room.  
Where does this ‘gut feel’ come from ?   I suspect years of experience – both in medicine and life.  As a Medical Educator or GP Supervisor, how do we translate this tacit knowledge – make the implicit explicit?   And as a learner, how do we develop these nuanced communication skills that are mentioned in GP curricula but not in any books?
The answer is reflective practice.   It’s not all about regurgitating the facts, and for those about to sit GP Fellowship exams, consider how ‘gut feel’, experience and interpretation impacts upon your decision making.  Most importantly, recognize how we balance the art of communication, the gathering of facts, and the management of uncertainty to ensure we are safe practitioners.  Yes, you must ‘know your stuff’ but if your patient doesn’t have a voice, you’ll have no clues to solve their problem.  GP exams pose a new challenge – all we have are the words on the page as clues – we are diagnosing in a communication vacuum and hence the importance of taking time to consider every key feature. Listening in the exam context is taking time to appreciate the clues in the stem and the context in which they are given.
Being a good clinician is about balancing art and science.   Ensure that you have gathered the key information, from the patient, ancillary information, collaborative history (or the question stem), and in context. Make sure that your initial differentials are broad – you can’t prioritize differentials that you haven’t considered in the first place.  
Recognize when your ‘gut’ is impacting on your decision-making.  Are you jumping to a diagnosis to early (I.e. premature closure)?   Are you seeking additional information to confirm what you’re thinking (I.e. Information bias)?   Have you seen many presentations like this recently (I.e. Availability bias)? Are you overconfident?

When a presentation seems straight-forward, the diagnosis is quick, emotive, decisive but very open to bias. When we are perplexed, our thinking is slow, measured, considered and objective. In these latter cases, we use hypotheses and deductions to reach conclusions, and that requires adequate rapport and communication. Knowing when we are diagnosing by pattern or by hypothesis is the skill of an expert clinician and reflection and communication is the key. Diagnosing in an exam should demonstrate deductive reasoning, but it’s tricky without the nuances of communication to guide us.

If the patient’s demeanor is closed, no degree of diagnostic strategizing will be helpful., and therein lies the art of active listening, and its role in clinical reasoning.

If you’re interested in learning more about clinical reasoning, type the tag in the search box for comprehensive blogs on the topic.

I’d encourage you to take a little extra time today to listen, and to reflect on the benefits and power of that privilege.

Please feel free to comment.

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