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How to ace your first patient encounter

As a medical student, you spend four years of college and the first two years of medical school studying non-stop for what feels like thousands of hours, cramming your brain with knowledge. But when the time comes to conduct your first face-to-face patient encounter, your confidence is rocked by the challenge of having to establish rapport, extract all the relevant medical history, and complete a physical exam, all while showing compassion, answering patient questions, and developing a differential diagnosis list and treatment plan in 30 minutes or less. Clinic is even worse with a meager 12 minutes scheduled for each patient encounter. 
Adding to the challenge, many of the skills you need to master a patient interaction aren’t learned from books or mastered in the school library. Your medical education provided the foundation for clinical reasoning and diagnostic skills. But while it emphasized the importance of building rapport with patients, truly listening, and showing compassion, and warned you about patient half-truths – when patients tell physicians what they think their doctor wants to hear, not what they actually did – these interpersonal skills are mastered through experience. With that in mind, here’s what you can do to make your first patient encounter a success.
Understand nonverbal communication. Body language is critically important: Eighty percent of communication between people is nonverbal. Think of how much you can deduce from a smile, an eye roll, or a shrug of the shoulders. Of course, this carries over into the exam room, where you can learn a lot about your patients through their body language. But remember, patients can also tell a lot about you – their doctor – by the way you’re standing, the expression on your face, and the position of your hands and arms.
Leaning slightly forward while taking patients’ history will show you’re interested in what they have to say, but folding your arms has the opposite effect and shuts the patient out. How you carry yourself in front of patients will impact their candidness and willingness to open up to you about their medical history and current symptoms, as well as their belief system and cultural biases.
Take an acting class, or better yet, take an improv class to hone your nonverbal communication skills. The skills and experience you gain will help you communicate better during your medical school entrance interviews as well as your patient encounters. Practice and refine these skills every day while interacting with your classmates or family members or while people watching at the mall, parks, or local bar with your friends.
Work on the other 20 percent. You’ve been communicating since you were a toddler, but now is the time to really work on your conversational skills. What you don’t say is just as important as what you do say.
Let the patient talk, and allow him or her to detail what aches and pains they’re experiencing. Listen and pay attention, and when you do ask a question, don’t interrupt the answer. Don’t overpower the conversation and sling question after question at the patient, as this feeds into the intimidation that many patients feel in the presence of their doctors.
Be compassionate. For example, when a patient allergic to bee stings describes the severe pain and swelling he or she experienced from an insect bite, a brief comment such as “that must have hurt a lot and been scary” shows you heard and understood their plight. Then you can proceed to ask about the type of insect, prior stings, and all the important medical stuff to determine the risk of anaphylaxis. The simple, compassionate comment takes less than four seconds to say, but is priceless in establishing rapport.
Memorize these 7 questions. Writers set the scene of an article by answering the five Ws: who, what, where, when, and why. In medicine we use the symptom seven. These seven questions assist us in fully understanding the chief complaint or symptom of the patient:
1. Symptom onset: Can you tell me when your [pain, cough, sore throat, etc.] started?
2. Symptom location: Can you point with one finger to the area of [pain, itch, rash, throat pain, etc.]?
3. Symptom scale: On a scale of 1 to 10, 10 being the worst pain you have ever experienced, how would you rank the [pain/discomfort] you are currently experiencing? Is it getting better, worse, staying the same?
4. Symptom quality: Can you describe the discomfort using strong adjectives, such as focal, shooting, burning, etc.?
5. Alleviating factors: Is there anything you can do to make it feel better?
6. Aggravating factors: Is there anything that makes it worse?
7. Associated symptoms: Do you have any associated symptoms, like a fever, rash, nausea, or vomiting?
Avoid the failure to communicate. Poor communication with your patient will lead to slowdowns in treatment, or worse yet, a misdiagnosis. To combat this, you must gently take control of the conversation. Maintain warmth and rapport with your patients, but don’t be afraid to take charge and ask direct questions. As a student (probably in your 20s), you’ll have many patients older than you who might try to control the conversation. You must be confident in your abilities and guide the discussion instead of simply following it.
Still, be aware of the cultural backgrounds and social norms of your patients. What’s appropriate and what’s considered a taboo? Can you speak with two people of different socio-economic backgrounds the same way?
Don’t forget this fact, either: We like to please others, which is why our patients will often stretch the truth or outright lie about their medical history, their current health, and their health habits. Understand that not all patients will be completely candid with you, and part of your job is to decipher their communication (both verbal and nonverbal) in order to separate the truths from the fictions.
You get 12 minutes with a patient, so make them count. Most patient interactions last less than 20 minutes. As a medical student, you’ll probably have more time than the average doctor, but it’s a fact that doctor-patient interactions are getting shorter and shorter, and you must become proficient at extracting all of the necessary information from a patient in a compressed amount of time.
You must maximize each second you’re with a patient, and you should be able to put together 80 percent of a diagnosis or hypothesis purely by asking questions, listening to the answers, and observing patients’ body language. Mastering these skills may not be your biggest challenge in medical school, but they are essential to having a long and rewarding medical practice.

J
Judith Kalinyak, MD, PhD, is the Director, Clinical Curriculum Integration for i-Human Patients, which develops virtual medical training products and services for medical, nurse practitioner, and physician assistant schools. Dr. Kalinyak has more than 15 years’ experience as a medical educator and... Judith Kalinyak, MD, PhD, is the Director, Clinical Curriculum Integration for i-Human Patients, which develops virtual medical training products and ...