Understanding The Importance Of Building A Rapport And Trust

   I recently started my indentured servitude, also known as third-year clinical rotations, and I have already picked up on some quirky behaviors from a select few patients.
While sitting in one of our examination rooms on a Monday morning, it occurred to me that patients could be fabricating stories for their personal protection. Alternatively, perhaps there is just a glitch in this human interaction.
A lot goes into taking an accurate history and physical. The patient and healthcare provider exchange quite a bit of information. However, the unspoken communication seems to take precedence over the verbal exchange.

   Let us start from the beginning. Put yourself in your patients’ shoes. From their perspective, you are coming into the relationship one step ahead. You have access to their medical records and some patients’ charts are as thick as novels. In the clinic environment, patients are seeing new faces each visit because of the frequency of students rotating through the various modules. The only information patients have to go on initially is your voice when you call their name to be seen, your appearance, facial expressions and the strength of your handshake when you first greet them.

   I have noticed guarding and expressions of surprise even when new patients are meeting the clinicians for the first time because all they know about the doctor is his or her last name. Perhaps some surnames sound more masculine than others and they are taken aback when they find out that the individual in charge of their care is a female or vice versa. As you make small talk while walking down the hallway to the examination room, first impressions are already embedded and hopefully you have established a good rapport.

   Now you are staring at each other in a small room with aseptic décor. After asking a few subjective questions, you begin the objective exam. Rhetorically speaking, how often have you felt like a patient was “faking” a protective sensation test? Have you ever changed your testing frequency and not applied the monofilament, but the patient states that he or she still feels it?

   I have to admit that some of the systemic conditions that patients are faced with are frightening. However, being in denial about the severity of their disease states does not lead to the best outcome. A skilled clinician, like a detective, can easily pick up on this type of behavior and provide appropriate education and support in order to aid the patient as much as possible.

   Another behavior that I have observed is what I like to call the “ever changing story” phenomenon. This can manifest itself in one of two ways. Perhaps the patient rebuts something that you previously wrote in the chart. An example may be an adherence issue although this could very easily be an error of the previous documenter.

   Alternatively, the patient may tell you one thing and comes up with a different answer when the doctor asks the same question. Perhaps the severity or location of pain changes or maybe there are unexplained alterations in the patient’s gait. This is difficult to deal with at times because it can make the first examiner seem incompetent.

   More seriously, there are patients who suffer from mental conditions (such as malingering or hypochondriasis) that can mask their physical health. Additionally, there are those who are involved in legal dilemmas such as worker’s compensation claims or lawsuits. Others may be illegally selling their pain medications.

   In these situations, one can only use his or her best judgment as there is no clear-cut manual on how to handle these incidents. At times, healthcare providers forget what it is like to be a patient but the goal remains the same and that is to provide the best care possible.

   There is a thin line between patient safety and protecting yourself. Podiatric physicians are faced with more than just diagnosing and treating conditions of the lower extremity. Often times, podiatrists must manage issues that are occurring at the opposite end of the body.

   Providing patient care is extremely rewarding and a privilege. However, in order to be a proficient clinician, good rapport must be present so the patient trusts the doctor and the doctor trusts the patient.

Ms. Ryans is a third-year student at the Temple University School of Podiatric Medicine and is in the class of 2010.

Dr. McCord recently retired from practice at the Centralia Medical Center in Centralia, Wash.