Evaluating Patients in the Office

The Office Visit – How I do it

It is important to learn how to perform an excellent evaluation of the patient in your office.  Significant amount of trust can be created from a relatively short period of interaction.

A good office visit starts with a good office staff.  It is your responsibility to assure a good experience, and it starts before you walk into the room.  If the patient comes in already having a  bad experience with scheduling, difficulty getting in touch with someone to ask questions, etc., the visit can be difficult, as a lack of trust already exists.  Among many of the good practices in pre-operative care, the nurses can help you by prepping the chart and gathering information so you know what to expect and have a plan about how to start the evaluation.

Preparation: review the images and patient history well before the visit

Listen to the patient: To get the full HPI, I usually say “You are here today by referral from Dr. Smith.  Can you walk me back to how you started getting chest xrays, stress test, etc”.  Then just sit and listen for a while.  After they feel you really know their symptoms and the background, you will gain trust, and be able to speak more freely.

Ask a series of questions about their history: previous surgery, smoking, blood thinners immunosuppressants , what do they do for a job (need to know so can prepare for discussion about activity restrictions later).

Exam: do a good exam, don’t skimp, the patient and family know a lousy exam when they see one.  It does help develop trust, and can break down barriers.  Patients who do not make eye contact with me before the physical exam, often become more comfortable and make eye contact after the exam.  If the first part of the visit is just not going well for some reason, jump to the exam, and see how it goes afterward.  Giving some verbal report on a normal exam is always comforting to the patient… “your lungs sound clear, heart sounds good”.  It only takes me a couple minutes to do the exam, but much is gained, tangible, and non-tangible.  Also, watching them get up on to the exam table is a good opportunity to see how well they can move. Positioning onto the exam table takes a certain amount of strength, balance, and cognitive ability, which are the very things they will need during their recovery.  This may be the only time you see them stand up and move around before surgery.

The crux of the appointment is now on.  It is your time to talk.

I can’t stress enough that an organized, well thought out process is essential.  It can really cause problems if a a good process is not in place.  The best process is one that answers almost all the questions along the way.  If it is simple but comprehensive, and can be easily remembered, it will benefit all.  Let me describe how I do it.

How I do it:

At this point, I tell the patient that there are three questions that need to be answered:

1) What surgery would I do?  Describe briefly the surgery that would be done based on the CT scan, angiogram, etc.  I draw a picture of it, their heart or lung, the tumor accurately showing the relative size, and location.  I have much preferred this over the models or demonstration videos because it has been my observation that they have less questions, and they feel like I drew their heart, or their lung.  Hopefully I leave them with the impression that I have studied the images enough to really know them, and their particular needs.

2) Should we do the surgery? Discuss the thought process in deciding to do the surgery – health history, how far they can walk, the CT scan findings, and whether I would recommend surgery or not.  Then the most important part, ask what they think about going ahead with surgery… they may need more information before being able to answer.

I walk through each step of the surgery, hospital course, initial phase of being home, when the office visit will be, and then the back to work or regular activity plan.

Then discuss the risks of surgery, and this leads into the benefits or why to do the surgery.

3) When should the surgery be done?  I save this topic for last, though many want to start initially with discussions about timing because it is very important to the family, due to worries about progression of the disease, work schedules etc.  Listen, re-assure, and take an active role in the discussion as it usually effects many people.

Talking with Family in the Waiting Room – how I do it

  1. Explain that the surgery is completed, seems obvious, but starts the conversation on the right foot.
  2. Tell them initially whether it went well or whether there were challenges – I say something like it went very smooth, or it was more challenging than what it typical, and then explain why.
  3. Explain what was done – take your time in this part
  4. This is a very important part!  Relate whether the patient was stable or not during the surgery – in a typical surgery I usually say something like “He/she was completely stable throughout, blood pressure, heart rate, oxygenation, and minimal bleeding”.  The family usually is relieved after hearing this part of the report.
  5. For the bigger surgical cases – I relate that the first hurdle is surgery, and the second hurdle is the first night, so still need to watch closely the BP, HR, oxygenation, and bleeding, etc.
  6. Where to go next, back to waiting room, or up to ICU.

Good luck, you will do great!