Informal Curriculum: Lesson 2.

An “infor­mal cur­ricu­lum” refers to lessons that are not explic­itly taught. In med­i­cine, there are skills doc­tors learn that are rarely recorded in text­books or overtly dis­cussed dur­ing rounds or lec­tures. How­ever, these are impor­tant skills that doc­tors need so they can work effec­tively with patients and col­leagues. Lessons in the infor­mal cur­ricu­lum include how to present patient infor­ma­tion to other doc­tors, how to dis­cuss end of life care with the fam­i­lies of patients, etc.

Con­trast this with the “for­mal cur­ricu­lum”, which focuses on top­ics such as anatomy, phys­i­ol­ogy, and using the lan­guage of the field. Con­trast this also with the “hid­den cur­ricu­lum”, which can include top­ics like how to hide med­ical errors, beliefs about the util­ity (or lack thereof) of dif­fer­ent types of physi­cians, etc.

In this series, I will share some lessons from the infor­mal cur­ricu­lum about inter­view­ing patients.1 I usu­ally teach these lessons to med­ical stu­dents. Other physi­cians, psy­chi­a­trists or not, may find them use­ful. If for noth­ing else, this pro­vides an oppor­tu­nity for all of us to con­sider how physi­cians can improve inter­ac­tions with patients.

I am pur­posely omit­ting the first rec­om­men­da­tion for now because it is para­mount, the most dif­fi­cult to define, and often chal­leng­ing to implement.

My sec­ond rec­om­men­da­tion: Ori­ent patients to the inter­view. Patients often don’t know what to expect dur­ing an ini­tial visit with a doc­tor. It takes less than 60 sec­onds to explain the ground rules of the game of the clin­i­cal inter­view. Doing this can help dis­pel some of the anx­i­ety patients may have about the meet­ing. It also gives physi­cians the oppor­tu­nity to shape the inter­view before it begins.

Make intro­duc­tions. Tell peo­ple your name. Ask patients for their name (and how they would pre­fer to be addressed). Though a power dif­fer­en­tial exists between doc­tor and patient, you’re both human beings. Good man­ners go a long way in build­ing a strong work­ing rela­tion­ship. The per­son in front of you is not just a patient: He is a per­son with hob­bies, strengths that you may not have, and a name. Acknowl­edge the per­son and at least learn his name.

Tell patients how much time you have together. In out­pa­tient set­tings, most patients gen­er­ally know how long appoint­ments will last. In inpa­tient set­tings, the sched­ule is less clear. In both loca­tions, how­ever, patients may have expec­ta­tions that you will spend much more time with them than you actu­ally can. Explic­itly announc­ing the amount of time avail­able can help estab­lish and main­tain focus on the pre­sent­ing problem.

Tell patients what will hap­pen dur­ing the inter­view. You don’t have to present a detailed itin­er­ary, but do give patients a gen­eral idea of what to expect. If you’ll be ask­ing a lot of ques­tions, say so. If you’ll be per­form­ing a pro­ce­dure, explain what will hap­pen. Peo­ple gen­er­ally don’t like sur­prises. Do your best to give patients enough infor­ma­tion so they can pre­pare them­selves for what’s next.

Tell patients that you might inter­rupt them. Some­times, some patients may start telling you things that they think you want to know. Some­times, this infor­ma­tion is irrel­e­vant. Because you only have lim­ited time together and you may need infor­ma­tion that patients may not think to tell you, tell patients that you might inter­rupt them before you ever do.

When I first meet patients, my pre­am­ble goes some­thing like this:

Hi. My name is Dr. Yang and I work as a psy­chi­a­trist. We have about 45 min­utes together. I’ll be ask­ing you a lot of ques­tions, some of which might make you won­der, “Why is she ask­ing me that?” If you find me inter­rupt­ing you, I’m not try­ing to be rude; I just want to make sure I get the right information.

It takes less than 30 sec­onds to say that. As a result, how­ever, I have essen­tially let the patient know:

  1. We have time together, but it is lim­ited. We’ll both try to stay focused on your concerns.
  2. You might find some of my ques­tions weird. Humor me.
  3. I intend to be cour­te­ous, but I might be impo­lite because I might need infor­ma­tion that you may not think to tell me.

With­out this ori­en­ta­tion, patients might end up telling me unnec­es­sary infor­ma­tion. They might feel vexed when I start ask­ing ques­tions they don’t expect (like when I ask about men­strual cycles, HIV sta­tus, or where they live). They might find my man­ner rude if I inter­rupt them to stay on track.

This is expec­ta­tion man­age­ment. And this can be one of the more impor­tant things we can do for patients.

  1. Back when I was a med­ical stu­dent, psy­chi­a­trists were still con­sid­ered the arti­sans of the clin­i­cal inter­view… and not just dis­pensers of psy­chi­atric med­ica­tions.