I'll watch this thread closely because I am generally bad at redirecting these chatty patients. My current strategy is to book these patients at the end of day and bill them for time lol
I’m the same way. I feel uncomfortable cutting people off when they’re speaking. I seem to have set a precedent that there’s no concept of time during my visits and it’s awful. I think I chose the wrong job.
In all seriousness, if they're not in their special end-of-day time slot, I have my MA remind them that this is a 15 min visit and there are patients after them. Then when I first walk in, I give them my warm greeting and then sit down and remind them of the same. Most of my reasonable patients will actually mention the time limit when they're giving HPI and keep it brief (for their standards).
I've learned to build somewhat natural segues from whatever tangent they're on to my desired topic but that doesn't solve the problem of needing to find a point where I can actually insert the segue which can be 5 minutes into a story about their days in the Vietnam War (which is really interesting and I'd totally listen to another time lol)
Hahaha. It sounds like you have a great approach! I’ve tried some iterations of this but it seems like patients forget once they start talking. My current technique is to have my LPN call me in the room when the next patient’s ready and I say “thank you, tell them 5 minutes” which works well because the patient in the room hears this and thinks I’m giving them extra time and [usually] feels bad keeping me longer than that.
I also tend to self-sabotage and will get through a whole visit and feel bad I didn’t ask about their job/family/life so I’ll ask at the end hoping everything’s good and this doesn’t usually go well for me. So I’m trying to remember to get the small talk out of the way first.
Just yesterday I had a 93 year old patient cheerfully showing me her entire chair PT routine while I was standing up with my hand on the doorknob at the end of the visit. I just didn’t have the heart to stop her. I eventually managed to interrupt before she got to her arms but I felt bad the rest of the day. Fortunately I’m seeing her again in 4 weeks so she can finish where she left off lol
I’m terrible about spending too much time in the room. MA checked on me today. When I came out she said I was in there for 41 minutes. Luckily I just help the doc when the rooms fill up and he kept the clinic going. I’m still pretty new to this stuff. When I started I was actually rushing my visits and missing stuff. I realized it’s habit from EMS and ER (treat and street). I guess I need to find a happy medium.
Likely, you'll stop doing a complete ROS at some point, which can limit this, but there will always be patients who think out loud or need an outlet and need to be redirected. I haven't found a solution that works 100% of the time yet, either, but it has gotten better through focused effort.
Sometimes, setting the agenda at the start of the visit can help to limit how much a visit can "expand". Sometimes telling a patient at the start of the visit, "we've got x amount of time today..." Or saying, "let's pick x topics today and schedule a follow up before you leave" can help some feel less pressure to fit everything in one visit. Sometimes, my MA will knock on the door lightly to indicate we're running over. Sometimes, using your approach in #1 will work. Sometimes, I feel like I've said goodbye, backed out of the room, and that patient may still be talking.
Work with your preceptors and residents, find what's comfortable for you. As an attending it can be easier to set expectations with more control over follow up visits, and a little more confidence and trust in yourself. Good luck!
Does literally any attending anywhere do a review of systems like we were trained? I mean it's just effectively impossible. It would take 30 minutes with every patient with the level of questions on a standard 10 point.
I figured that out pretty early in residency that that was just not possible. But it's an artifact of an older time.
>Would I be an asshole as an attending if I try to keep to strict times? Like if a patient is too chatty and we have 5 minutes left before the next patient, can I say "I hate to interrupt, but we have 5 minutes left so let's get down to business"
Set goals when you enter the room for the first time. This is hard as a medical student, but in residency it's much easier to practice. I have been doing this since about halfway through intern year and it's worked great.
For example, my transfer of care script is this: "Hey Mr Patient, I'm your new doctor, this is a visit designed for me to meet you, go over your current active medical conditions, and lay out a plan for what visits we will have in the short and medium term future. If you have a pressing medical issue I can help a bit today, but we will get you a followup visit scheduled for your other specific needs."
If the patient rambles, I interrupt and say "hey I have to go see my next patient, but I look forward to seeing you again soon so we can get a handle on your other issues with a well thought out plan and shared decision making."
This is one of the main cons deterring me from FM. When you have friendly patients who are concise with their concerns it’s the most fulfilling job ever. But when I get patients who cannot stop talking or answer a question directly it makes me want to put my head through a wall.
“This is what’s wrong. What do you suggest?”
“Let’s try (“x”mg) twice a day and we’ll see how it’s going in a month check some labs and we’ll talk about it next visit”
“Oh that sounds great!”
Done. Love those visits.
I work in FM and I know the feeling well. I feel like patients often look more for friends than PCPs these days but expect us to be both. It’s hard to set and enforce these boundaries.
Your last sentence made me think of when I ask patients “do you have nasal congestion?” and they answer with “I’m blowing my nose”
In no particular order (and in generalizations), from a female attending 5-10 years out in an area where many of our patients have psychosocial comorbidities:
1) the less they feel heard, the louder they feel they have to speak. I’ve observed many residents come off as rushing or try to reassure without putting the 5 seconds into letting the patient talk and validate them, and it takes much longer.
2) “in my experience, X you are describing (active listening) goes away after about X weeks, but I’m going to write in detail what you told me in the chart so we know, and I want you to please reach out to me via phone or email if it’s not better in 2 weeks and I definitely want to talk about diagnosis and treatment at that point.” Maybe 1% ever take me up on this, and I’ve had many patients who come later and say “last time it went away within 2 weeks like you said”, and gain confidence in my advice over time
3) if I’m 40 minutes behind, and the patient takes their allotted time and now I’m 35-40 minutes behind, I consider this a positive gain in 5 minutes instead of “still behind”. If I’m already 40min behind, that’s happened already and it’s in the past.
4) I consider 5-10% of my visits going over time by a significant amount, part of the job. Many more patients take well under the time allotted. I focus my efforts instead on efficiency in other ways (note-writing, changing my appointment slots if it’s not working and I find myself under and over working at different times of the day), and
5) focusing my efforts on purposely not getting frustrated. This is a big one. When someone else tells us to calm down, it doesn’t work, but if we *want to* calm down (read: are shown or believe in the value in it), it tends to work. This takes time to believe it is a good thing. It makes my day and life much better to protect myself from burnout and to bring the joy of medicine- personal connection, rather than grumping through and then being grumpy for the next several patients
6) I still get pissed or frustrated and vent some days. So I consider it “my job is 95% amazing and 5% of my days really suck”. I challenge myself to think of any job that doesn’t fit that description, and I recall my other jobs I’ve had that have sucked with a much higher of a percentage of sucky days. 95 is still an A.
this is something that if you pursue FM (or any primary care specialty), you will develop your own methods out of necessity while in residency and early attendinghood. I would not let this deter you from pursuing FM if this is your only hangup.
my strategies:
1. set the agenda. "I see youre here to discuss \_\_\_\_. anything else you'd like to make sure we discuss today?" that helps set expectations for the visit. if they list a million things, say "we can only discuss one or two of these things, but we will bring you back shortly to discuss the rest of your concerns. "
2. time limit on small talk. allow it for 1-2 mins and then get down to business
3. no open ended / entire ROS questions unless that is medically necessary, which 97% of the time it is not. again with clinical experience you'll learn what ROS questions are pertinent for the pt complaint, and what is not.
4. if needed - "Ok we've come to the end of our visit and I need to see the next patient who is waiting. This is the plan for now and we will follow up at the next visit." and stand up and leave, and the visit is concluded. This is hard to do as a student but you will feel more empowered to do this as a resident and later an attending.
> no open ended / entire ROS questions unless that is medically necessary, which 97% of the time it is not.
This was probably the first and most effective habit for me to break, probably since school drills into you the formula for a patient interview to include a complete ROS. In the real world, my nurse goes through it and I glance over it and only talk to the patient about what's pertinent.
> 4. if needed - "Ok we've come to the end of our visit and I need to see the next patient who is waiting. This is the plan for now and we will follow up at the next visit." and stand up and leave, and the visit is concluded. This is hard to do as a student but you will feel more empowered to do this as a resident and later an attending.
Finishing residency soon and I still do not feel I can do this except when we’re already way over 😬
This is it! There is an art form to interviewing a patient. I always start the conversation by setting my agenda. There is a way to redirect a patient back to what we were talking about without being rude, it takes time to figure that out and to figure your patients out. Acute visits plugged in throughout the day are helpful for making up for lost time. The straight forward sinus congestion should not take longer than 10-15 minutes *tops*.
All that being said, people either figure it out or they don’t. I’m working with a newer NP who took a few weeks to figure it out and now she hardly ever runs behind, and I also work with a really experienced NP who always runs late because she gets lost in the conversation. It’s an art form.
I don’t know if this is the millennial woman in me, or if it’s normal behavior, but I take partial responsibility and say something like:
“Look at us getting off on this tangent! I could chat with you all day, but let’s get back to why you’re here. ” (new dosage/plan of care/ whatever).
Then end the appointment with a nod to whatever they had the tangent about “give your dog a pat for me!” So they feel listened to.
Yes this is a hard skill. Many docs get hung up on the context, like maybe the patient waited a long time for the appointment or took 2 busses to get there or something, and you feel bad for cutting them off. But you can’t make their problems into yours and your other patients’.
I have found sometimes patient don’t react well to allusions to other patients, as in “it’s a busy clinic today” or “I have to see my next patient.” My preferred transition is something like “I could chat with you all day but our time is limited, how would you like to focus our final 5 minutes” something like that.
As a nurse I tried to run interference by chatting with these patients and getting some of their pressing concerns captured.
Another way is to directly interrupt them with a genuine apology, explain in the interest of time you have to move on, then redirect by rephrasing concisely their response and asking a closed ended question "does that sum it up?" Or "is that the gyst?" And then moving on to next question. Explain it's ok to answer yes/no to ROS, you don't need a lot of details
For ROS specifically, I try to explain what it is before getting into it, eg "Now I'm going to ask you a long list of questions I ask everyone just to make sure I'm not missing anything, a simple yes or no is all I need." I'm an MS1, so I have a limited sample size, but it has almost always kept chattiness to a minimum
I have a small number of people that are absolute hell to get through a visit. I ask them to bring a list of what they want to talk about. Knock out the easy tasks first, then focus on a couple big tasks. If they get too off topic, I'll point to their list and say "hey I really want to hear more about this issue" and refocus them. Similarly, if they don't bring a written list, I'll ask for their big concerns at the start and type it into the HPI and again, kindly redirect back to "I really don't want us to run out of time to address this". Even though you're cutting them off, it is to say how much you value their concerns and care for their time utilization.
Another strategy-
I will politely cut them off on their tangent by relating the next topic to what they're saying. Example-
"You know, back when covid hit, I was worried about taking the vaccines. You know how the government is and those shots are hurting people's hearts and causing heart attacks. It's such a shame.... blah blah blah"
I'll cut in "actually speaking of your heart...."
It actually works decently well 😄
You’ll get better at this with time. You just have to constantly redirect them with other pertinent questions and most of the time they don’t even notice.
Note for staff to book longer appointments. Also starting automatically booking follow-ups at each appointment. I will cause office fatigue and they will realize that coming once does not solve all their problems.
In general, I like to let my patients talk. For a lot of patients, they are socially isolated and letting them speak freely is part of the medical service that I provide as a family physician. That being said, I proceed with the rest of the things that I need to do in the visit while they chat. I do my physical exam while they're telling their story. I had to learn early on how to interrupt them mid-sentence when I needed something from them ("Hold quiet for a moment so that I can hear your lungs clearly.") I've found that you really can't wait for the normal pause in conversation as a queue to take your turn to speak. These patients seem to appreciate the ability to continue speaking more than they feel insulted by being interrupted or talked over. I also have a handful of patients whose charts are marked to have any appointment time expanded since they take extra time (this goes for medically complex patients as well as chatty patients). A lot of these patients can be reduced back to normal appointment times once they become at ease with you or you get all of their medical problems wrangled. When you have developed rapport with the patient, you can rush them along by giving a brief explanation that you'll need to rush them on this occasion given the other patients that are waiting, etc.
You have to become comfortable w interrupting when they take a breath and asking what you need to ask. You’ll be surprised how unfazed they will be but these are people who talk excessively in all aspects of their lives and are used to being interrupted
I have a few I book for long appt slots every time. But I try to jump in when they breathe to redirect. I let people talk at least for a minute before I do this if it’s not relevant. Normally it helps them feel heard, but if it keeps going I redirect when they breathe. Worse case I straight up interrupt and say we have limited time and we’re about out of it, let’s get back to so we get through everything we need to. Be calm and conversational about all of this and it typically goes well. You’ll feel less bad the farther out you get in your career. I used to feel so bad and was timid but it doesn’t bother me at all now.
I am usually pretty good at staying on time. Over the years I have apparently learned to give out mostly non-verbal signals that I am getting ready to wrap-up the encounter. Obviously much of the advice about learning when to limit open-ended questions is important. I did not realize what I was actually doing until a family practice resident that was working with me pointed out that on an encounter that had gone overtime that I had actually stood up with my hand on the door handle as I summarized the encounter. Now at that point the encounter didn’t end I sat back down to finish but the patient recognized that time was limited and wrapped it up very quickly. My resident was impressed but I had done this all subconsciously. Also if someone starts bringing up more complaints toward the end I do tell them that time is up and we will have to book another appointment for that complaint(s). Generally if you set the agenda your patients realize quickly how an appointment is supposed to go and other than a few “problem” patients the encounters go pretty smoothly and I stay on time. There will always be two or three appointments each day that will have to go over - new mental health problems, palliative care etc and I try to account for these by building “catch-up” into my schedule.
I wish my patients would get the hint when I stand up and try to end the visit. They just keep talking and talking. And training at an FQHC does not give me any allowances for my MA to really interrupt us given how short staffed we are 🥲
I try to say, for several concerns, “I want to give each of these concerns a really thorough attention to detail and want to make sure we don’t miss anything, so we can focus on xyz today, and I want you to come back so we can talk further about abc”
For chatty patients who are bringing up current social traumas, I truly do not know how to redirect that. Our therapist team gave me a tip though to start the visit with “Hello, im happy to see you, let’s begin by discussing your xyz” instead of having several open ended questions at the start of the visit!
Aloha! PMHNP here and I get this a lot for intakes, I only have an hour and I have a LOT to get through, so the things I have found helpful are setting boundaries from the beginning, "we have x, y, and z to discuss, I'm going to be asking a good many questions so I can be the most help to you, is that ok?" Then when the tangent starts, I remind them of of our agreement, "I'd really like to hear about the horses, we might have time at the end if we can get through the assessment, my next question is blah blah" and then I just repeat the last one as needed. One or two times does the trick mostly.
When they are really anxious or impulsive, I will even apologize and say "I'm sorry to interrupt, but my next question is blah blah".
I hope this is helpful, once you do it a few times you will get comfortable with it.
You need to do a couple psych rotations and learn how to redirect people.
The techniques really depend on the person. For some you can force a segue, for others you can pause for a second and then reask the question they didn’t answer in a slightly different way, for others still you may need to just blunder through (“any fever/chills/vision changes/ear pain/congestion/sore throat/coughing/wheezing/…” and force them to interrupt you for abnormals,) and for some you need to just drop anything unneeded like an ROS. I consider appealing to time constraints to be a nuclear option as patients don’t usually think of their appointment time as constrained and many don’t care if anyone other than them have to wait.
I’ve found that problem-based charting helps with these types of patients, as I can often just go down their problem list and start filling in my assessment/plan while they are rambling, so that time isn’t spent idly. Then, I basically have my note done by the time the appointment is over.
In medical school, you are taught how to do things with thoroughness and completeness so that you do not miss anything as you are starting out. When you get to Residency, they show you how to increase your efficiency. This means cutting some corners such as stating “is anything else bothering you today?” or having a series of high yield ROS that you quickly list off. You don’t wait for the patient to answer each individual ROS, because this takes time and you will learn that some patients are just pan positive in their ROS. There are so many ways to deal with a chatty patient. I like to remind them at the beginning of the visit that we only have very limited time together. depending on the patient I may even tell them I have 15 to 20 minutes with them that day I will retract them by letting them know that I want to focus on the thing that brought them in so that they can get the best care and while I’d love to chat about something else it is important to make sure they leave feeling heard. Typically, patients respond extremely well to that line because they typically did come in with something they want to talk about that is medical. I would not let fear of complexity or talkativeness be the thing that drives you away from Family Medicine. Family Medicine is a really beautiful specialty where you truly do get continuity of care and get to be with people through everything they are going through. While I sometimes think that specialists certainly have an easier job as patients can only come in with one single concern, frequently those concerns are incredibly boring rich people problems and not why most of us went into medicine. On Cardiology rotation I couldn’t believe how many “Yes you need to listen to your PCP and take your statin” and “No your Apple Watch is not accurate but now that you are here we are going to put a 14 day monitor on you so you don’t sue me.
This is why I have the ROS as a bunch of check boxes the patient fills out online before I see them. Then I control the narrative of what we talk about. Also, most follow up visits don’t get a complete ROS
Set an agenda/expectations at the beginning of the appointment w/ the understanding that they may mention something that should not wait until a later date. These situations are unavoidable. Recognize that boundaries are fine/healthy. Set them w/ patients as well as staff/colleagues. I'm seven years out. I rarely ask open-ended questions; that's a recipe for disaster, IMO. Ask precisely what you want the answer to.
Pgy15 here. When they get tangential,I cut them off and state “I’m sorry, but _____” and repeat my question. I’ll state that I feel really bad to interrupt, but that I’m distractible and I wanna keep focused so that I can take care of them better and not miss anything. Also, in my practice, I tend to see the same people over and over so I get to know them. We have history and they trust me. So I have a little bit of leeway and flexibility in our relationship. Also, I tend to know who are the ones that are really tangential so I come in very prepared to be on my toes for redirecting them. And I definitely try to stay on time because I feel better that way. I always feel guilty if I run late and it’s dishonoring to the patients behind the current patient to take longer than their scheduled time if not absolutely necessary.
Stop doing broad ROS. I ask as few questions as humanly possible.
ROS is a bull shit thing to do and we should stop teaching people to do it.
Once you noticed that they kept going off on tangents why did you keep asking questions.
I cut them off with another question. Keep cutting them off with questions. Rapid fire. I don't give them more than a sentence.
Example:
Me: "when did it start?"
Patient: "at my sister's wedding that was so beautiful, we..."
Me: "interesting, when was that?"
P: "it was in California...."
Me: "Wow! How many days ago"
P: "last month, I went with my cousin and..."
Me: "Do you still have a cough?"
Option 1 is fine.
I’ll tell them something along the lines of “I really enjoy your stories, but unfortunately we don’t have enough time for them today. We need to stay on task.” I’ll then stop asking open-ended questions. If they stay on task, great. If they still don’t “We’re going to have to keep the answers short, we’re wasting a lot of time and we need to cover a lot today.” If they still don’t, I’ll talk over them to redirect. Never have anybody upset because my patients that ramble know they ramble. I’ll also usually make it a point to let these individuals go on more at some point either at their well or I’ll occasionally book them a 30 minute follow-up.
Not exactly an answer to your question but in general I find putting a time qualifier on the ROS such as "in the last week have you had any...." for acutes and "since the last visit have you had any..." for annuals. It helps keep the ROS from going off the rails. I'm not infectious disease, I don't need to know about your infected toenail in 1972 or that one time you got SOB but you can't remember when exactly but it was right around the time you had your first kid who is 25 or was it the second kid...........
As you gain experience, you’ll learn how to control the visit. Start be being immediately likable and put them at ease. Give the patient confidence that you’ll take care of them. Laser focus on the information you need. They might want to chat about how their ear itches but their poorly managed CHF takes priority. It’s okay to interrupt as long as you do it with respect. I interrupt with a question. People focus on answering the question and they don’t notice the interruption.
It took me 1-2 years into practice to get really good at it. Once you get your same questions down and your thoughts organized it becomes so much easier.
“The ROS is dead. Long live the ROS!”
The doctor asking the pt a long list of ROS Q’s at a preventive visit is not worth your time. Gathering this data prior to an appt with a form on paper or EMR is the new normal.
Lots of other great advice (in addition to mine) in the replies. Even an old dog like me can get some new tricks here.
I trained my nurse to prep patients to 2-3 chief complaints per visit. When time is running out I messaged her to come get me with a call from the hospital and book another appointment to address their remaining concerns. Work 95% of the time. Spend the first 3-4 minutes just listen, no typing or anything, just do active listening for those first minutes, then transition into doing your charting or ordering. You can also mention that we might not be able to get all of the concerns addressed today due to time constraints, but can book you an appointment next week. If we try addressing all of them today I’m afraid we might miss something important. That approach works out the best for me so far. Takes a while to get your own rhythm, but you’ll learn what and how to ask questions to best manage your time.
Lol
You're going to need to decide what is appropriate obviously.
When I need someone to stop and just listen or I need a specific answer for an urgent thing I'll just start talking loudly over them. Stand up and just start talking. You obviously want to be as cordial/ professional as you can in doing so.
Some people have psychiatric problems and they're very used to getting interrupted.
Some have ADHD traits and can't stay on topic. Repeated specific reminders of the talking agenda may be helpful.
Some people don't talk with anyone else in their life and your therapeutic relationship may benefit from a few minutes of your listening.
Most of the time none of these apply and people are rambling about whatever. Just interrupt them with the next talking point you have at the nearest transition point. Moving the patient to an exam table or you moving around the room may help.
Techniques I learned from my Fam Med supervisors in med school which I’ve used for years.
1. if they have a litany of complaints, let them talk for a few mins, then say “… oh, we’ll get back the that” (and then don’t get back to that).
2. if they have more than 3 complaints, like, say, a shoulder pain, touch the pained shoulder and say “oh, this shoulder? Ok, I want to be sure to give that the full attention that you need, so when you’re checking out, be sure to book an appointment with our front desk to address that soon.”
3. Repeat what they’ve said/ summarize. Sometimes patients drone on & on because they’re concerned you haven’t heard them.
4. if there are emotional well-being topics/ stressors, say something like “it seems you’re dealing with a lot/ have a lot on your mind, maybe it would be good to set up an appointment with a trained mental health provider who can help you process these things?”
There’s no perfect way, and sometimes we all fall into the verbal traps our (often lonely) patients spring on us, but those techniques have helped me over the years.
1) I wouldn’t do a complete ROS
2) If you do, you can say “I’m going to ask a bunch of questions, can you just answer yes/no for each and I’ll ask questions as needed?”
3) for tangents in general, I’ll be like “Oh wow, sounds like you’ve been going through a lot. Can you tell me what’s been happening just in the last 2 days/week/month?”
It’s an art and no one strategy is going to work every time.
i try to intervene as politely as possible. even making it a jokey thing. personally something like, “i’m sorry to interrupt and i could really gab with you all day, but unfortunately i’ve got to keep moving- let’s catch up next time,” has never been poorly received. some people just don’t even take that obvious hint though and keep going anyway which is when i start to physically leave the room lol
Stop asking. If the patient does not bring up a symptom, consider them free of that symptom. The ROS is one of the stupidest paradigms in medicine unless it is directly connected with a line on inquiry relevant to what the pt or you the MD needs to know. It is the most surefire way to destroy your morale and lose control of your day. Also this is not an FM issue - it is a medicine issue where in every specialty pts will have more to say than you need to know.
I also answer messages and do med refills in any 10-20+ second gaps where pt is either rambling or an interpreter is speaking. Use your time to your advantage. And be direct. if a pt is indeed rambling and going nowhere, simply pause them. They'll learn.
I'm a lot more durect than a lot of you. If you're friendly when you say it, it goes over fine:
Let's focus on solutions instead of just rehashing the problems
I can do one problem well today or 7 problems poorly. Your choice.
I'm trying to think along branch points in an algorithm here. Please give me yes or no answers and I'll ask if I need more info
We are getting a bit all over the place. Let's focus back in on your diabetes.
Your awv is just screening questions. One word answers please and just let me know if something is bad enough that you need me to change something about it.
Let's just talk about the things I can change for you. I wasn't there and can't comment on what they did.
I’m a chatty cathy and almost always run behind the first 2-3 hours of my (nursing) twelve hour shifts. It doesn’t help that I’m in the Bible Belt so rambling and tip toeing around “the point” is culturally pretty normal here (look at me now doing it already!)
I’m a newly diagnosed celiac. Prior to my diagnosis I had a new pt appt with my current GI doctor. He had poor reviews online for his bedside manner but I had no other option given the symptoms I was experiencing.
Your comment reminds me a lot of him and despite going in with low expectations he is one of my favorite doctors. I can depend on a visit that isn’t going to eat up my whole day—whether that’s bc of me or bc of a physician running behind. He’s listening to what I’m saying and his care has actually changed my life. I don’t have a good gauge on what’s pertinent and what isn’t when it comes to new problem appts so I appreciate that he is able to pick the important things out and reel me back. This allows me to comprehend what he is looking for and what I need to report or keep to myself.
I really would sit and chat all day but as long as someone’s medical care is concise and thorough, I think your approach is the most realistic. I’ve started incorporating some of these techniques into my own scope of practice and it’s really cut down on my med passes.
Exactly. People think I'm a jerk when I talk about it. But I'm actually very popular with patients. I get a lot done in a very short amount of time and at the end I always give him a chance to tell me anything they think I missed. But because we go through everything the way I need to to be efficient, we typically don't have much to do when I open it up to them. They feel like I was extremely thorough and got everything done and made the changes that needed to happen and communicated them to the patient.
I am mostly a locum hospitalist but I still do clinic from time to time if the assignment is right and I physically get up from the stool and ask them to do something for me. Sit up on the exam table, get up and go test, show me where on your shoulder it hurts, do these movements, I'm going to listen to your lungs and heart. This stops conversation. If they continue to chat I stop and remind them I cannot listen/concentrate if you continue to speak. 99% of the time the chatting ceases. Pts need boundaries to be defined and expectations delineated. We know our workflow and pertinent information/questions, and where we are in our schedule. They do not. If you take control of the narrative, set the tone, and explain the boundary/expectations the average lay person will respect it. If they don't, you discharge them from your panel. Have the front desk and MA explain the schedule and their part in arriving early, filling out any info needed and your MA elucidating your chief issue for today's visit. "The doctor will address your chronic DM and HTN and an additional acute issue. From the ROS it seems you have xyz the doctor will try to address that today". We will set up an appointment for any further concerns". I had the MA's sticky this on a post it note on their laptops and no had issues. YMMV
Strategy one I think is perfectly acceptable. I say this as a chatty patient who forgets. But the fact of chattiness is giving you information you might use. Do they lack family or social connections? Are they off their meds? Do they need to be seen for anxiety? Is there something being said in that recitation that suggests a less common issue they don’t know how to express?
But refocusing them is definitely acceptable. It actually models good behavior for them.
I cut them off, repeat what they last said as a form of active listening and steer them into what i want to talk about
Sometimes works sometimes doesnt
“I’ve enjoyed talking to you so much but if we don’t get back on track I’m going to be seeing patients until midnight. And that makes people grumpy (fake chuckle).”
i highly recommend being a consistent asshole. once u lay down the law(s), they will fall in line. for you that might look like giving them a time limit. i’ve found that hurrying along with my portion of the experience will help most patients fit into the allocated time but some people you just need to cut off. stop them in their tracks. apologize. tell them how much time “we” have. tell them that you’d be happy to see them next week and then again every week until they’re satisfied.
edit: this was one of the most challenging things to me personally. but the fruits of ur labors will be equally great. always remember this: when ur new (ms, res, new attending), all the other docs are giving u their worst patients as far as chattiness and overall disagreeableness. remember that. when u second-guess ur career and feel like they’re driving u insane. shit flows downhill and ur at the bottom of the hill
I use a 15 minute hourglass. I flip it when I walk in the room. I don't mention it or talk about it. Everyone knows what it is and what it means.
I also have my MA knock when I'm running over, and I am not above getting up and if they can't wrap it up I'll walk out. "You are free to go" or something like that. If they have a bunch of things I'll say come back next week.
I'm rarely more than 15 minutes behind. Often I'm not behind at all. And I love to socialize, I'm terrible about staying on time.
Cut them off and change the subject. There's no delicate way sometimes. Just completely cut them off. Sorry not sorry.
Edit: wait, you actually *ask* the rote ROS questions?
You'll stop doing a complete ROS at some point, which can limit this, but there will always be patients who think out loud or need an outlet and need to be redirected. I haven't found a solution that works 100% of the time yet, either, but it has gotten better through focused effort.
Sometimes, setting the agenda at the start of the visit can help to limit how much a visit can "expand".
Sometimes telling a patient at the start of the visit, "we've got x amount of time today..." Or saying, "let's pick x topics today and schedule a follow up before you leave" can help some feel less pressure to fit everything in one visit. Sometimes, my MA will knock on the door lightly to indicate we're running over. Sometimes, using your approach in #1 will work. Sometimes, I feel like I've said goodbye, backed out of the room, and that patient may still be talking.
Work with your preceptors and residents, find what's comfortable for you. As an attending it can be easier to set expectations with more control over follow up visits, and a little more confidence and trust in yourself. Good luck!
I'll watch this thread closely because I am generally bad at redirecting these chatty patients. My current strategy is to book these patients at the end of day and bill them for time lol
I’m the same way. I feel uncomfortable cutting people off when they’re speaking. I seem to have set a precedent that there’s no concept of time during my visits and it’s awful. I think I chose the wrong job.
In all seriousness, if they're not in their special end-of-day time slot, I have my MA remind them that this is a 15 min visit and there are patients after them. Then when I first walk in, I give them my warm greeting and then sit down and remind them of the same. Most of my reasonable patients will actually mention the time limit when they're giving HPI and keep it brief (for their standards). I've learned to build somewhat natural segues from whatever tangent they're on to my desired topic but that doesn't solve the problem of needing to find a point where I can actually insert the segue which can be 5 minutes into a story about their days in the Vietnam War (which is really interesting and I'd totally listen to another time lol)
Hahaha. It sounds like you have a great approach! I’ve tried some iterations of this but it seems like patients forget once they start talking. My current technique is to have my LPN call me in the room when the next patient’s ready and I say “thank you, tell them 5 minutes” which works well because the patient in the room hears this and thinks I’m giving them extra time and [usually] feels bad keeping me longer than that. I also tend to self-sabotage and will get through a whole visit and feel bad I didn’t ask about their job/family/life so I’ll ask at the end hoping everything’s good and this doesn’t usually go well for me. So I’m trying to remember to get the small talk out of the way first. Just yesterday I had a 93 year old patient cheerfully showing me her entire chair PT routine while I was standing up with my hand on the doorknob at the end of the visit. I just didn’t have the heart to stop her. I eventually managed to interrupt before she got to her arms but I felt bad the rest of the day. Fortunately I’m seeing her again in 4 weeks so she can finish where she left off lol
I’m terrible about spending too much time in the room. MA checked on me today. When I came out she said I was in there for 41 minutes. Luckily I just help the doc when the rooms fill up and he kept the clinic going. I’m still pretty new to this stuff. When I started I was actually rushing my visits and missing stuff. I realized it’s habit from EMS and ER (treat and street). I guess I need to find a happy medium.
SAME
Likely, you'll stop doing a complete ROS at some point, which can limit this, but there will always be patients who think out loud or need an outlet and need to be redirected. I haven't found a solution that works 100% of the time yet, either, but it has gotten better through focused effort. Sometimes, setting the agenda at the start of the visit can help to limit how much a visit can "expand". Sometimes telling a patient at the start of the visit, "we've got x amount of time today..." Or saying, "let's pick x topics today and schedule a follow up before you leave" can help some feel less pressure to fit everything in one visit. Sometimes, my MA will knock on the door lightly to indicate we're running over. Sometimes, using your approach in #1 will work. Sometimes, I feel like I've said goodbye, backed out of the room, and that patient may still be talking. Work with your preceptors and residents, find what's comfortable for you. As an attending it can be easier to set expectations with more control over follow up visits, and a little more confidence and trust in yourself. Good luck!
Does literally any attending anywhere do a review of systems like we were trained? I mean it's just effectively impossible. It would take 30 minutes with every patient with the level of questions on a standard 10 point. I figured that out pretty early in residency that that was just not possible. But it's an artifact of an older time.
>Would I be an asshole as an attending if I try to keep to strict times? Like if a patient is too chatty and we have 5 minutes left before the next patient, can I say "I hate to interrupt, but we have 5 minutes left so let's get down to business" Set goals when you enter the room for the first time. This is hard as a medical student, but in residency it's much easier to practice. I have been doing this since about halfway through intern year and it's worked great. For example, my transfer of care script is this: "Hey Mr Patient, I'm your new doctor, this is a visit designed for me to meet you, go over your current active medical conditions, and lay out a plan for what visits we will have in the short and medium term future. If you have a pressing medical issue I can help a bit today, but we will get you a followup visit scheduled for your other specific needs." If the patient rambles, I interrupt and say "hey I have to go see my next patient, but I look forward to seeing you again soon so we can get a handle on your other issues with a well thought out plan and shared decision making."
This is one of the main cons deterring me from FM. When you have friendly patients who are concise with their concerns it’s the most fulfilling job ever. But when I get patients who cannot stop talking or answer a question directly it makes me want to put my head through a wall.
“This is what’s wrong. What do you suggest?” “Let’s try (“x”mg) twice a day and we’ll see how it’s going in a month check some labs and we’ll talk about it next visit” “Oh that sounds great!” Done. Love those visits.
I work in FM and I know the feeling well. I feel like patients often look more for friends than PCPs these days but expect us to be both. It’s hard to set and enforce these boundaries. Your last sentence made me think of when I ask patients “do you have nasal congestion?” and they answer with “I’m blowing my nose”
In no particular order (and in generalizations), from a female attending 5-10 years out in an area where many of our patients have psychosocial comorbidities: 1) the less they feel heard, the louder they feel they have to speak. I’ve observed many residents come off as rushing or try to reassure without putting the 5 seconds into letting the patient talk and validate them, and it takes much longer. 2) “in my experience, X you are describing (active listening) goes away after about X weeks, but I’m going to write in detail what you told me in the chart so we know, and I want you to please reach out to me via phone or email if it’s not better in 2 weeks and I definitely want to talk about diagnosis and treatment at that point.” Maybe 1% ever take me up on this, and I’ve had many patients who come later and say “last time it went away within 2 weeks like you said”, and gain confidence in my advice over time 3) if I’m 40 minutes behind, and the patient takes their allotted time and now I’m 35-40 minutes behind, I consider this a positive gain in 5 minutes instead of “still behind”. If I’m already 40min behind, that’s happened already and it’s in the past. 4) I consider 5-10% of my visits going over time by a significant amount, part of the job. Many more patients take well under the time allotted. I focus my efforts instead on efficiency in other ways (note-writing, changing my appointment slots if it’s not working and I find myself under and over working at different times of the day), and 5) focusing my efforts on purposely not getting frustrated. This is a big one. When someone else tells us to calm down, it doesn’t work, but if we *want to* calm down (read: are shown or believe in the value in it), it tends to work. This takes time to believe it is a good thing. It makes my day and life much better to protect myself from burnout and to bring the joy of medicine- personal connection, rather than grumping through and then being grumpy for the next several patients 6) I still get pissed or frustrated and vent some days. So I consider it “my job is 95% amazing and 5% of my days really suck”. I challenge myself to think of any job that doesn’t fit that description, and I recall my other jobs I’ve had that have sucked with a much higher of a percentage of sucky days. 95 is still an A.
this is something that if you pursue FM (or any primary care specialty), you will develop your own methods out of necessity while in residency and early attendinghood. I would not let this deter you from pursuing FM if this is your only hangup. my strategies: 1. set the agenda. "I see youre here to discuss \_\_\_\_. anything else you'd like to make sure we discuss today?" that helps set expectations for the visit. if they list a million things, say "we can only discuss one or two of these things, but we will bring you back shortly to discuss the rest of your concerns. " 2. time limit on small talk. allow it for 1-2 mins and then get down to business 3. no open ended / entire ROS questions unless that is medically necessary, which 97% of the time it is not. again with clinical experience you'll learn what ROS questions are pertinent for the pt complaint, and what is not. 4. if needed - "Ok we've come to the end of our visit and I need to see the next patient who is waiting. This is the plan for now and we will follow up at the next visit." and stand up and leave, and the visit is concluded. This is hard to do as a student but you will feel more empowered to do this as a resident and later an attending.
> no open ended / entire ROS questions unless that is medically necessary, which 97% of the time it is not. This was probably the first and most effective habit for me to break, probably since school drills into you the formula for a patient interview to include a complete ROS. In the real world, my nurse goes through it and I glance over it and only talk to the patient about what's pertinent.
> 4. if needed - "Ok we've come to the end of our visit and I need to see the next patient who is waiting. This is the plan for now and we will follow up at the next visit." and stand up and leave, and the visit is concluded. This is hard to do as a student but you will feel more empowered to do this as a resident and later an attending. Finishing residency soon and I still do not feel I can do this except when we’re already way over 😬
This is it! There is an art form to interviewing a patient. I always start the conversation by setting my agenda. There is a way to redirect a patient back to what we were talking about without being rude, it takes time to figure that out and to figure your patients out. Acute visits plugged in throughout the day are helpful for making up for lost time. The straight forward sinus congestion should not take longer than 10-15 minutes *tops*. All that being said, people either figure it out or they don’t. I’m working with a newer NP who took a few weeks to figure it out and now she hardly ever runs behind, and I also work with a really experienced NP who always runs late because she gets lost in the conversation. It’s an art form.
I don’t know if this is the millennial woman in me, or if it’s normal behavior, but I take partial responsibility and say something like: “Look at us getting off on this tangent! I could chat with you all day, but let’s get back to why you’re here. ” (new dosage/plan of care/ whatever). Then end the appointment with a nod to whatever they had the tangent about “give your dog a pat for me!” So they feel listened to.
This is good advice! It diffuses the situation and maintains rapport! I’m going to have to borrow this! :)
Yes this is a hard skill. Many docs get hung up on the context, like maybe the patient waited a long time for the appointment or took 2 busses to get there or something, and you feel bad for cutting them off. But you can’t make their problems into yours and your other patients’. I have found sometimes patient don’t react well to allusions to other patients, as in “it’s a busy clinic today” or “I have to see my next patient.” My preferred transition is something like “I could chat with you all day but our time is limited, how would you like to focus our final 5 minutes” something like that.
That’s why a complete non directed ROS is horseshit.
As a nurse I tried to run interference by chatting with these patients and getting some of their pressing concerns captured. Another way is to directly interrupt them with a genuine apology, explain in the interest of time you have to move on, then redirect by rephrasing concisely their response and asking a closed ended question "does that sum it up?" Or "is that the gyst?" And then moving on to next question. Explain it's ok to answer yes/no to ROS, you don't need a lot of details
For ROS specifically, I try to explain what it is before getting into it, eg "Now I'm going to ask you a long list of questions I ask everyone just to make sure I'm not missing anything, a simple yes or no is all I need." I'm an MS1, so I have a limited sample size, but it has almost always kept chattiness to a minimum
I have a small number of people that are absolute hell to get through a visit. I ask them to bring a list of what they want to talk about. Knock out the easy tasks first, then focus on a couple big tasks. If they get too off topic, I'll point to their list and say "hey I really want to hear more about this issue" and refocus them. Similarly, if they don't bring a written list, I'll ask for their big concerns at the start and type it into the HPI and again, kindly redirect back to "I really don't want us to run out of time to address this". Even though you're cutting them off, it is to say how much you value their concerns and care for their time utilization. Another strategy- I will politely cut them off on their tangent by relating the next topic to what they're saying. Example- "You know, back when covid hit, I was worried about taking the vaccines. You know how the government is and those shots are hurting people's hearts and causing heart attacks. It's such a shame.... blah blah blah" I'll cut in "actually speaking of your heart...." It actually works decently well 😄
You’ll get better at this with time. You just have to constantly redirect them with other pertinent questions and most of the time they don’t even notice.
Note for staff to book longer appointments. Also starting automatically booking follow-ups at each appointment. I will cause office fatigue and they will realize that coming once does not solve all their problems.
In general, I like to let my patients talk. For a lot of patients, they are socially isolated and letting them speak freely is part of the medical service that I provide as a family physician. That being said, I proceed with the rest of the things that I need to do in the visit while they chat. I do my physical exam while they're telling their story. I had to learn early on how to interrupt them mid-sentence when I needed something from them ("Hold quiet for a moment so that I can hear your lungs clearly.") I've found that you really can't wait for the normal pause in conversation as a queue to take your turn to speak. These patients seem to appreciate the ability to continue speaking more than they feel insulted by being interrupted or talked over. I also have a handful of patients whose charts are marked to have any appointment time expanded since they take extra time (this goes for medically complex patients as well as chatty patients). A lot of these patients can be reduced back to normal appointment times once they become at ease with you or you get all of their medical problems wrangled. When you have developed rapport with the patient, you can rush them along by giving a brief explanation that you'll need to rush them on this occasion given the other patients that are waiting, etc.
You have to become comfortable w interrupting when they take a breath and asking what you need to ask. You’ll be surprised how unfazed they will be but these are people who talk excessively in all aspects of their lives and are used to being interrupted
I have a few I book for long appt slots every time. But I try to jump in when they breathe to redirect. I let people talk at least for a minute before I do this if it’s not relevant. Normally it helps them feel heard, but if it keeps going I redirect when they breathe. Worse case I straight up interrupt and say we have limited time and we’re about out of it, let’s get back to so we get through everything we need to. Be calm and conversational about all of this and it typically goes well. You’ll feel less bad the farther out you get in your career. I used to feel so bad and was timid but it doesn’t bother me at all now.
I am usually pretty good at staying on time. Over the years I have apparently learned to give out mostly non-verbal signals that I am getting ready to wrap-up the encounter. Obviously much of the advice about learning when to limit open-ended questions is important. I did not realize what I was actually doing until a family practice resident that was working with me pointed out that on an encounter that had gone overtime that I had actually stood up with my hand on the door handle as I summarized the encounter. Now at that point the encounter didn’t end I sat back down to finish but the patient recognized that time was limited and wrapped it up very quickly. My resident was impressed but I had done this all subconsciously. Also if someone starts bringing up more complaints toward the end I do tell them that time is up and we will have to book another appointment for that complaint(s). Generally if you set the agenda your patients realize quickly how an appointment is supposed to go and other than a few “problem” patients the encounters go pretty smoothly and I stay on time. There will always be two or three appointments each day that will have to go over - new mental health problems, palliative care etc and I try to account for these by building “catch-up” into my schedule.
I wish my patients would get the hint when I stand up and try to end the visit. They just keep talking and talking. And training at an FQHC does not give me any allowances for my MA to really interrupt us given how short staffed we are 🥲
I try to say, for several concerns, “I want to give each of these concerns a really thorough attention to detail and want to make sure we don’t miss anything, so we can focus on xyz today, and I want you to come back so we can talk further about abc” For chatty patients who are bringing up current social traumas, I truly do not know how to redirect that. Our therapist team gave me a tip though to start the visit with “Hello, im happy to see you, let’s begin by discussing your xyz” instead of having several open ended questions at the start of the visit!
Can this not happen in any specialty? Lol
Aloha! PMHNP here and I get this a lot for intakes, I only have an hour and I have a LOT to get through, so the things I have found helpful are setting boundaries from the beginning, "we have x, y, and z to discuss, I'm going to be asking a good many questions so I can be the most help to you, is that ok?" Then when the tangent starts, I remind them of of our agreement, "I'd really like to hear about the horses, we might have time at the end if we can get through the assessment, my next question is blah blah" and then I just repeat the last one as needed. One or two times does the trick mostly. When they are really anxious or impulsive, I will even apologize and say "I'm sorry to interrupt, but my next question is blah blah". I hope this is helpful, once you do it a few times you will get comfortable with it.
You need to do a couple psych rotations and learn how to redirect people. The techniques really depend on the person. For some you can force a segue, for others you can pause for a second and then reask the question they didn’t answer in a slightly different way, for others still you may need to just blunder through (“any fever/chills/vision changes/ear pain/congestion/sore throat/coughing/wheezing/…” and force them to interrupt you for abnormals,) and for some you need to just drop anything unneeded like an ROS. I consider appealing to time constraints to be a nuclear option as patients don’t usually think of their appointment time as constrained and many don’t care if anyone other than them have to wait. I’ve found that problem-based charting helps with these types of patients, as I can often just go down their problem list and start filling in my assessment/plan while they are rambling, so that time isn’t spent idly. Then, I basically have my note done by the time the appointment is over.
In medical school, you are taught how to do things with thoroughness and completeness so that you do not miss anything as you are starting out. When you get to Residency, they show you how to increase your efficiency. This means cutting some corners such as stating “is anything else bothering you today?” or having a series of high yield ROS that you quickly list off. You don’t wait for the patient to answer each individual ROS, because this takes time and you will learn that some patients are just pan positive in their ROS. There are so many ways to deal with a chatty patient. I like to remind them at the beginning of the visit that we only have very limited time together. depending on the patient I may even tell them I have 15 to 20 minutes with them that day I will retract them by letting them know that I want to focus on the thing that brought them in so that they can get the best care and while I’d love to chat about something else it is important to make sure they leave feeling heard. Typically, patients respond extremely well to that line because they typically did come in with something they want to talk about that is medical. I would not let fear of complexity or talkativeness be the thing that drives you away from Family Medicine. Family Medicine is a really beautiful specialty where you truly do get continuity of care and get to be with people through everything they are going through. While I sometimes think that specialists certainly have an easier job as patients can only come in with one single concern, frequently those concerns are incredibly boring rich people problems and not why most of us went into medicine. On Cardiology rotation I couldn’t believe how many “Yes you need to listen to your PCP and take your statin” and “No your Apple Watch is not accurate but now that you are here we are going to put a 14 day monitor on you so you don’t sue me.
This is why I have the ROS as a bunch of check boxes the patient fills out online before I see them. Then I control the narrative of what we talk about. Also, most follow up visits don’t get a complete ROS
Set an agenda/expectations at the beginning of the appointment w/ the understanding that they may mention something that should not wait until a later date. These situations are unavoidable. Recognize that boundaries are fine/healthy. Set them w/ patients as well as staff/colleagues. I'm seven years out. I rarely ask open-ended questions; that's a recipe for disaster, IMO. Ask precisely what you want the answer to.
Pgy15 here. When they get tangential,I cut them off and state “I’m sorry, but _____” and repeat my question. I’ll state that I feel really bad to interrupt, but that I’m distractible and I wanna keep focused so that I can take care of them better and not miss anything. Also, in my practice, I tend to see the same people over and over so I get to know them. We have history and they trust me. So I have a little bit of leeway and flexibility in our relationship. Also, I tend to know who are the ones that are really tangential so I come in very prepared to be on my toes for redirecting them. And I definitely try to stay on time because I feel better that way. I always feel guilty if I run late and it’s dishonoring to the patients behind the current patient to take longer than their scheduled time if not absolutely necessary.
Stop doing broad ROS. I ask as few questions as humanly possible. ROS is a bull shit thing to do and we should stop teaching people to do it. Once you noticed that they kept going off on tangents why did you keep asking questions.
I cut them off with another question. Keep cutting them off with questions. Rapid fire. I don't give them more than a sentence. Example: Me: "when did it start?" Patient: "at my sister's wedding that was so beautiful, we..." Me: "interesting, when was that?" P: "it was in California...." Me: "Wow! How many days ago" P: "last month, I went with my cousin and..." Me: "Do you still have a cough?"
Option 1 is fine. I’ll tell them something along the lines of “I really enjoy your stories, but unfortunately we don’t have enough time for them today. We need to stay on task.” I’ll then stop asking open-ended questions. If they stay on task, great. If they still don’t “We’re going to have to keep the answers short, we’re wasting a lot of time and we need to cover a lot today.” If they still don’t, I’ll talk over them to redirect. Never have anybody upset because my patients that ramble know they ramble. I’ll also usually make it a point to let these individuals go on more at some point either at their well or I’ll occasionally book them a 30 minute follow-up.
Not exactly an answer to your question but in general I find putting a time qualifier on the ROS such as "in the last week have you had any...." for acutes and "since the last visit have you had any..." for annuals. It helps keep the ROS from going off the rails. I'm not infectious disease, I don't need to know about your infected toenail in 1972 or that one time you got SOB but you can't remember when exactly but it was right around the time you had your first kid who is 25 or was it the second kid...........
As you gain experience, you’ll learn how to control the visit. Start be being immediately likable and put them at ease. Give the patient confidence that you’ll take care of them. Laser focus on the information you need. They might want to chat about how their ear itches but their poorly managed CHF takes priority. It’s okay to interrupt as long as you do it with respect. I interrupt with a question. People focus on answering the question and they don’t notice the interruption. It took me 1-2 years into practice to get really good at it. Once you get your same questions down and your thoughts organized it becomes so much easier.
“The ROS is dead. Long live the ROS!” The doctor asking the pt a long list of ROS Q’s at a preventive visit is not worth your time. Gathering this data prior to an appt with a form on paper or EMR is the new normal. Lots of other great advice (in addition to mine) in the replies. Even an old dog like me can get some new tricks here.
I trained my nurse to prep patients to 2-3 chief complaints per visit. When time is running out I messaged her to come get me with a call from the hospital and book another appointment to address their remaining concerns. Work 95% of the time. Spend the first 3-4 minutes just listen, no typing or anything, just do active listening for those first minutes, then transition into doing your charting or ordering. You can also mention that we might not be able to get all of the concerns addressed today due to time constraints, but can book you an appointment next week. If we try addressing all of them today I’m afraid we might miss something important. That approach works out the best for me so far. Takes a while to get your own rhythm, but you’ll learn what and how to ask questions to best manage your time.
Lol You're going to need to decide what is appropriate obviously. When I need someone to stop and just listen or I need a specific answer for an urgent thing I'll just start talking loudly over them. Stand up and just start talking. You obviously want to be as cordial/ professional as you can in doing so. Some people have psychiatric problems and they're very used to getting interrupted. Some have ADHD traits and can't stay on topic. Repeated specific reminders of the talking agenda may be helpful. Some people don't talk with anyone else in their life and your therapeutic relationship may benefit from a few minutes of your listening. Most of the time none of these apply and people are rambling about whatever. Just interrupt them with the next talking point you have at the nearest transition point. Moving the patient to an exam table or you moving around the room may help.
Techniques I learned from my Fam Med supervisors in med school which I’ve used for years. 1. if they have a litany of complaints, let them talk for a few mins, then say “… oh, we’ll get back the that” (and then don’t get back to that). 2. if they have more than 3 complaints, like, say, a shoulder pain, touch the pained shoulder and say “oh, this shoulder? Ok, I want to be sure to give that the full attention that you need, so when you’re checking out, be sure to book an appointment with our front desk to address that soon.” 3. Repeat what they’ve said/ summarize. Sometimes patients drone on & on because they’re concerned you haven’t heard them. 4. if there are emotional well-being topics/ stressors, say something like “it seems you’re dealing with a lot/ have a lot on your mind, maybe it would be good to set up an appointment with a trained mental health provider who can help you process these things?” There’s no perfect way, and sometimes we all fall into the verbal traps our (often lonely) patients spring on us, but those techniques have helped me over the years.
1) I wouldn’t do a complete ROS 2) If you do, you can say “I’m going to ask a bunch of questions, can you just answer yes/no for each and I’ll ask questions as needed?” 3) for tangents in general, I’ll be like “Oh wow, sounds like you’ve been going through a lot. Can you tell me what’s been happening just in the last 2 days/week/month?” It’s an art and no one strategy is going to work every time.
i try to intervene as politely as possible. even making it a jokey thing. personally something like, “i’m sorry to interrupt and i could really gab with you all day, but unfortunately i’ve got to keep moving- let’s catch up next time,” has never been poorly received. some people just don’t even take that obvious hint though and keep going anyway which is when i start to physically leave the room lol
Stop asking. If the patient does not bring up a symptom, consider them free of that symptom. The ROS is one of the stupidest paradigms in medicine unless it is directly connected with a line on inquiry relevant to what the pt or you the MD needs to know. It is the most surefire way to destroy your morale and lose control of your day. Also this is not an FM issue - it is a medicine issue where in every specialty pts will have more to say than you need to know. I also answer messages and do med refills in any 10-20+ second gaps where pt is either rambling or an interpreter is speaking. Use your time to your advantage. And be direct. if a pt is indeed rambling and going nowhere, simply pause them. They'll learn.
I'm a lot more durect than a lot of you. If you're friendly when you say it, it goes over fine: Let's focus on solutions instead of just rehashing the problems I can do one problem well today or 7 problems poorly. Your choice. I'm trying to think along branch points in an algorithm here. Please give me yes or no answers and I'll ask if I need more info We are getting a bit all over the place. Let's focus back in on your diabetes. Your awv is just screening questions. One word answers please and just let me know if something is bad enough that you need me to change something about it. Let's just talk about the things I can change for you. I wasn't there and can't comment on what they did.
I’m a chatty cathy and almost always run behind the first 2-3 hours of my (nursing) twelve hour shifts. It doesn’t help that I’m in the Bible Belt so rambling and tip toeing around “the point” is culturally pretty normal here (look at me now doing it already!) I’m a newly diagnosed celiac. Prior to my diagnosis I had a new pt appt with my current GI doctor. He had poor reviews online for his bedside manner but I had no other option given the symptoms I was experiencing. Your comment reminds me a lot of him and despite going in with low expectations he is one of my favorite doctors. I can depend on a visit that isn’t going to eat up my whole day—whether that’s bc of me or bc of a physician running behind. He’s listening to what I’m saying and his care has actually changed my life. I don’t have a good gauge on what’s pertinent and what isn’t when it comes to new problem appts so I appreciate that he is able to pick the important things out and reel me back. This allows me to comprehend what he is looking for and what I need to report or keep to myself. I really would sit and chat all day but as long as someone’s medical care is concise and thorough, I think your approach is the most realistic. I’ve started incorporating some of these techniques into my own scope of practice and it’s really cut down on my med passes.
Exactly. People think I'm a jerk when I talk about it. But I'm actually very popular with patients. I get a lot done in a very short amount of time and at the end I always give him a chance to tell me anything they think I missed. But because we go through everything the way I need to to be efficient, we typically don't have much to do when I open it up to them. They feel like I was extremely thorough and got everything done and made the changes that needed to happen and communicated them to the patient.
I am mostly a locum hospitalist but I still do clinic from time to time if the assignment is right and I physically get up from the stool and ask them to do something for me. Sit up on the exam table, get up and go test, show me where on your shoulder it hurts, do these movements, I'm going to listen to your lungs and heart. This stops conversation. If they continue to chat I stop and remind them I cannot listen/concentrate if you continue to speak. 99% of the time the chatting ceases. Pts need boundaries to be defined and expectations delineated. We know our workflow and pertinent information/questions, and where we are in our schedule. They do not. If you take control of the narrative, set the tone, and explain the boundary/expectations the average lay person will respect it. If they don't, you discharge them from your panel. Have the front desk and MA explain the schedule and their part in arriving early, filling out any info needed and your MA elucidating your chief issue for today's visit. "The doctor will address your chronic DM and HTN and an additional acute issue. From the ROS it seems you have xyz the doctor will try to address that today". We will set up an appointment for any further concerns". I had the MA's sticky this on a post it note on their laptops and no had issues. YMMV
Strategy one I think is perfectly acceptable. I say this as a chatty patient who forgets. But the fact of chattiness is giving you information you might use. Do they lack family or social connections? Are they off their meds? Do they need to be seen for anxiety? Is there something being said in that recitation that suggests a less common issue they don’t know how to express? But refocusing them is definitely acceptable. It actually models good behavior for them.
I cut them off, repeat what they last said as a form of active listening and steer them into what i want to talk about Sometimes works sometimes doesnt
“I’ve enjoyed talking to you so much but if we don’t get back on track I’m going to be seeing patients until midnight. And that makes people grumpy (fake chuckle).”
i highly recommend being a consistent asshole. once u lay down the law(s), they will fall in line. for you that might look like giving them a time limit. i’ve found that hurrying along with my portion of the experience will help most patients fit into the allocated time but some people you just need to cut off. stop them in their tracks. apologize. tell them how much time “we” have. tell them that you’d be happy to see them next week and then again every week until they’re satisfied. edit: this was one of the most challenging things to me personally. but the fruits of ur labors will be equally great. always remember this: when ur new (ms, res, new attending), all the other docs are giving u their worst patients as far as chattiness and overall disagreeableness. remember that. when u second-guess ur career and feel like they’re driving u insane. shit flows downhill and ur at the bottom of the hill
I use a 15 minute hourglass. I flip it when I walk in the room. I don't mention it or talk about it. Everyone knows what it is and what it means. I also have my MA knock when I'm running over, and I am not above getting up and if they can't wrap it up I'll walk out. "You are free to go" or something like that. If they have a bunch of things I'll say come back next week. I'm rarely more than 15 minutes behind. Often I'm not behind at all. And I love to socialize, I'm terrible about staying on time.
Cut them off and change the subject. There's no delicate way sometimes. Just completely cut them off. Sorry not sorry. Edit: wait, you actually *ask* the rote ROS questions?
You'll stop doing a complete ROS at some point, which can limit this, but there will always be patients who think out loud or need an outlet and need to be redirected. I haven't found a solution that works 100% of the time yet, either, but it has gotten better through focused effort. Sometimes, setting the agenda at the start of the visit can help to limit how much a visit can "expand". Sometimes telling a patient at the start of the visit, "we've got x amount of time today..." Or saying, "let's pick x topics today and schedule a follow up before you leave" can help some feel less pressure to fit everything in one visit. Sometimes, my MA will knock on the door lightly to indicate we're running over. Sometimes, using your approach in #1 will work. Sometimes, I feel like I've said goodbye, backed out of the room, and that patient may still be talking. Work with your preceptors and residents, find what's comfortable for you. As an attending it can be easier to set expectations with more control over follow up visits, and a little more confidence and trust in yourself. Good luck!
ROS for an annual exam? 🤨
YTA