Establishing rapport

Blog #4
by Nishani

The CanMEDS roles emphasize the importance of a physician as a skilled communicator, advocate, manager, scholar, professional, medical expert, and collaborator.   In our curriculum, these skills are continuously evaluated in every clerkship rotation.  We are also expected to reflect on these roles through our portfolio submissions.  Occasionally, the roles are taught formally through lectures and small group clinical sessions based on themes such as ethics, breaking bad news, and dealing with a difficult patient. However, I believe I learned the most about these roles through observing my preceptors and residents.  To that end, I did not realize just how much I learned about establishing rapport and working with patients with addictions until today.

I saw Mr. X in clinic for follow up 1 month after discharge from hospital for a condition related to his high alcohol consumption.  He came with his caseworker and the first thing he stated was that he did not have a lot of time and did not want to wait around for the attending staff.   I told him that it would take a bit of time to be able to provide him with the best care possible, and he seemed agreeable to this.  I made a conscious effort to build rapport during the history taking and physical examination using various techniques that I picked up over time from many of my preceptors and residents.  I then left to review his case.  Shortly after, I was informed that he wanted to leave. My preceptor and I met him outside the clinic and he stated that he felt anxious and wanted to step outside to smoke.  I asked him if he would consider returning after he was done. I told him that we might be able to provide him with some suggestions to help relieve his symptoms that he stated were bothering him so much.  He declined and left.  I was slightly disappointed, but hopeful that he might return.  Through my experience working at an inner city hospital for most of my core rotations and dealing with many patients with addictions, I had almost a “sixth sense,” as my staff called it, that the patient would return.  Indeed, he did.  We were able to complete his assessment, and determine the necessary management and follow up for his condition.  

This encounter reminded me that there are many skills taught in medical school that are not presented through formal teaching sessions.  Having good role models and mentors to teach students significantly adds to this part of the curriculum.  Although no preceptor prefaced this kind of teaching with, “now you will learn about how to establish rapport with someone who does not want to see you,” and I cannot name one specific encounter where I learned “how to reason with a patient who wants to leave against medical advice,” I have learned several strategies to work with these kinds of situations over time through careful observation.