An Approach to the Patient Encounter

This post is intended to provide you with a general approach to the patient encounter. Keep in mind that each case and each patient will be different. However, with a general template in mind, you may find that interacting with the standardized patients is less anxiety-provoking.

We encourage you to keep in mind how you were taught to interact with patients during medical school. Those numerous patient interactions will provide you with a framework with which to work during this examination. If you have uncertainties about your comfort with the standardized patient, if you did not get enough patient interactions during medical school, or if you are unfamiliar with the American medical system, this post should provide you with valuable information. In addition, the cases in our book are designed to mimic the cases on the USMLE Step 2 CS, so working through the cases and repeating the cases should only enhance your comfort with the standardized patient.

Before entering the room with the standardized patient, knock confidently on the door and walk in with a smile while making eye contact. Offer your hand to shake and introduce yourself, "Hello, I'm Student-doctor Smith. How may I help you today."

After the introduction, sit down and face the patient. You may consider asking the patient if he or she is comfortable sitting where they are. Then tell the patient that you will be taking a few notes during the encounter. "If you don't mind, I'm going to take a few notes as we speak to help me provide you with the best care possible." Some people would argue that you should ask permission to take notes, but in real-world medicine, the physician does not ask for permission to take notes, so we don't feel that you need to ask if this is okay.

While taking a few brief notes, be sure to maintain eye contact and give the patient the impression that you are listening. Nod your head as the patient speaks, respond to the patient's questions, and repeat back important points. "So, your back pain began only after you twisted the wrong way and you've had the pain for three days." This emphasizes the point that you are listening, improves the accuracy of your history, and allows the patient to correct you if you have missed anything.

During the history-taking portion of the encounter, focus on the patient's main complaint and ask questions that relate to the complaint. Ask about duration, intensity, exacerbating and alleviating factors, and other associated symptoms. In a future post, we will discuss this part of the history in more detail.

When asking questions related to the social history, you may wish to frame the questions. For example, you may say "I have a few personal questions to ask you that will help me understand your concerns a bit better and will allow me to take better care of you." You may then proceed to ask questions relating to alcohol use, smoking, drug use, or sexuality. Likewise, you may wish to frame the family history with a similar introduction.

Before examining the patient, be sure to wash your hands! While washing the hands, you may wish to ask a few additional questions or even make casual (but not too casual or friendly) conversation with the patient.

As you examine the patient, explain what you are doing, why you are doing it, and what your findings are. When needed, give the patient specific instructions. For example, "I am going to listen to your heart to determine if you have any murmurs." You may then instruct the patient to sit forward or lie down as you listen to the heart. Then, you might say, "Your heart sounds very normal."

When examining the patient, be sure to drape the patient in a professional and courteous manner. When examining the abdomen, the groin should be draped, covering it as much as possible. Sensitive issues regarding the examination of the patient will be discussed in a future post.

When you have finished with your examination, return to your seat and quickly collect your thoughts. At this point, you should summarize the visit for the patient to check for accuracy and to make sure the patient understands. This also allows the patient to add any additional details as necessary. At this point, you should also tell the patient your plan of care. You may tell the patient, "I think that your back pain is caused primarily by muscle spasm. However, I would like to rule out other causes such as arthritis or infection, so I am going to order an x-ray and some blood work."

At this point, remember that you may also need to counsel the patient. If there are issues such as cigarette use, drug use, or excessive alcohol intake, this should be discussed with the patient.

Ask the patient if he or she understands everything that you have discussed. If they ask questions, try to answer them as well as you can without making anything up. If you are unsure of the answer, tell them "I will have to look that up and get back to you with an answer." You may even say, "I'm not sure. I'll discuss that question with my attending physician and get back to you." After determining that the patient understands what you have said, ask the patient if he or she has any additional questions that you can answer.

Finally, tell that patient that it was a pleasure meeting him or her, shake hands, and leave the room.


All rights reserved worldwide. Copyright 2005, Theodore X. O'Connell, M.D.