(from the May 2019 ACP Internist)
‘The Pause’ allows physicians a chance to reflect upon a diagnosis or how to communicate with patients, as well as reset their mindset throughout the day.
By Robert M. McLean, MD, FACP
I have the pleasure and honor of serving as President of the College for the next year. In that role, I will have the opportunity to travel to ACP chapters around the world and represent the College in many different settings. I also have the opportunity, through this monthly column, to express reflections on the College's work and how it relates to a career in internal medicine and the ever-changing world of healthcare delivery.
As we physicians entered the culture of medicine and learned how to be internists, the experiences that shaped us led us to develop certain behaviors to get through our day. Many of these behaviors are second nature or rote habits by now.
I was recently struck by a relative describing a visit with a family member to see a medical subspecialist for a consult. There was a good bit of complicated lab work to consider, and while speaking to the patient and family members in the room, the physician said, “I need a few minutes to think about this.” And they sat there while he perused various pieces of information in the electronic medical record (EMR), stopping to think occasionally, with no conversation, for a full five minutes! The relative reported to me how thrilled they were that he was really taking the opportunity to focus in an uninterrupted way.
I realized that the doctor was very overtly exhibiting “The Pause.”
We all do it at times. Some do it much more thoughtfully than others. It most frequently occurs at the moment of transition before we enter an exam room in our office/clinic or a patient's room in the hospital. We simultaneously do several tasks: We transition from the patient we just saw, needing to clear our mind and be ready for the next person with complete focus. We reflect on what has been going on with that next person(clinical changes, test results to review, other physicians seen). We compose how we might explain all that, how we plan to react to delivering news, good or bad, and we start to consolidate all this into next-step plans.
“The Pause” originated in part with explicit techniques around interviewing, history taking, and data gathering that we learned as medical students. And some of that learning and role modeling likely became fine-tuned during residency training.
We learned this behavior as students and residents in the hospital on morning rounds, seeing our patients with the team. The team would stop in the hall outside the patient's room, and the responsible clinician, usually the intern, would explain current status and plans for the day and entertain questions from the rest of the team. Then the resident or attending physician would frequently use the opportunity to make teaching points.
At those times, we were experiencing an appropriate pause to gather our thoughts before walking into the room and interacting with our patient. We didn't call it that, but it is what we were doing. It is a behavior that became part of our physician culture.
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ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products, and activities of ACP.