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Leveling With Patients

Ben_3Ben Bryner -- Many of the most valuable lessons from the third and fourth years of medical school aren't formally taught. Even when the lessons are obvious or are explicitly taught, they actually sink in when you learn them from patients or from attendings at work. One good example of this was the way I learned to always level with patients.

While doing an abdominal exam, you always want to look for something called "rebound tenderness." Of course, Rebound Tenderness would be a great title for a medically-themed romance novel. But in normal usage, rebound tenderness is found when the examiner pushes on the abdomen, then suddenly lets go, and at that point the patient experiences severe pain. When you practice this on healthy classmates or standardized patients, it's no big deal and doesn't hurt. In this artificial setting, you usually check for rebound tenderness in the course of your abdominal exam. You press down to feel for masses, and on the last one you hold pressure, then suddenly lift your hand and watch for a grimace. Fair enough. But when this test is useful, like on sick patients in the ER for whom you have to make a relatively fast decision on treatment, it's not so pleasant. Especially when the test is positive.

One of my attendings taught me what he felt was a better way to do this: at the bedside in the ER, explain to the patient beforehand exactly what you're doing and briefly explain the theory behind the test. ("If it hurts more when I lift my hand off your belly than when I press down, that makes x more likely," etc.) On the way to the ER he explained that this way you can build the patient's trust instead of undermining it, which is crucial if you're going to announce in a minute that you’re wheeling him or her back for an urgent operation. He went over the history that the resident and I had taken, did an exam, and when the woman did indeed have some rebound tenderness she was grateful for the warning.

Some might object that this makes the test less effective because the patient is already expecting some pain. But even if this was true, you'd never base your treatment decision squarely on the presence or absence of rebound tenderness. As far as I can see, my attending's way was a better way to go about it. Whether in medicine or anywhere else, it's often so hard to regain the trust of a patient, client, or friend after it's been broken, so whatever you can do to avoid that seems worth it.

I learned a similar lesson from one of my patients in an outpatient medicine clinic at the VA. Like many of his compatriots at the VA, he suffered from a constellation of diseases known as "VA comorbidities" like COPD, diabetes, coronary artery disease, etc. (It seems that everybody has a different nickname for this collection of diseases -- the name is different but the conditions are the same.) He said, “They don't..." well, actually, I'm not going to quote him, because, again like many of his fellow veterans, he enjoyed his curse words a great deal. (I'm not going to begrudge him that, but it's not ideal for reprinting in this distinguished forum.) Anyway, he said how much he appreciated that his doctors at the VA gave him an honest assessment of his condition, a thorough listing of his options, and had a frank discussion of the odds that his treatments would work. Whether you're in the ER seeing a patient you've never met, or in an outpatient clinic with a patient you've seen many times, continually building trust is critical.

January 24, 2008 in Ben Bryner | Permalink


Okay, I know that this won't aid the topic in any way buuuut I just wanted to say that upon reading the title the first thing I thought of was World of Warcraft. Some of you are gonna get this, and some of you won't.

Ya, ya, I know how nerdy. :)


Posted by: Benjamin | Jan 29, 2008 3:08:10 PM

With decades of care giving for mentally ill people behind and likely ahead of me, I have had occasions to read full psyh and medical files. It is astonishing to see how often the real issue (diagnosis) was never brought up to the patient. Apparently because the patient was not ready to hear it and would bolt from the health provider. But even so if the second and or third professional leveled with the patient as well the real issues could of been addressed in the early stages instead of just treating the after math.

Posted by: Stephen Casey | Jan 29, 2008 7:50:16 PM

You are so correct in the damage done by the loss of trust in patients who are not leveled with. I'm an x ray tech and if I had a dollar for every patient who came to the rad dept for an exam who had no clue why eh/she was having the exam or even what the exam was! I can say that these folks were not thrilled.

Imagine my predicament when one day I had to explain to a patient that he was sent down for a BE. This lucent and very aware patient did not know what a BE was, so I explained the exam, he was angry and refused. Although my area is just one aspect of their care in hospital, they often will vent their dissatisfaction with things. One theme is getting to talk to their physican concerning exams and treatment.."whats going on".

I hope you continue to value your patients trust and keep them informed, It makes a huge difference in patient cooperation, satisfaction and respect for the care you give them.

Posted by: AB | Jan 29, 2008 9:27:08 PM

Trusted and informed patients are not only for better treatments, but it also reduce unnecessary lawsuits when they think they are misguided.

Posted by: Anonymous | Jan 30, 2008 10:50:39 AM

I agree 100% with the principle of everything you said. However, it's a colossal waste of time to explain the principle of rebound tenderness or any other physical finding which may be uncomfortable to a patient. The time explaining adds up in a hurry--especially when the inevitable questions arise from the superfluous explanation. In this case, overly-preparing a patient for something they think will hurt might cause some degree of abdominal "guarding" and skew the findings.

A simple, "OK, this might hurt--sorry if it does--let me know," with a quick rebound check accomplishes both goals without sacrificing anything and takes 3-4 seconds. If an unmistakable positive sign is found, I can then explain what that might mean, so that further testing/tx as you mentioned is seen in its proper context.

Posted by: Realism | Jan 30, 2008 12:34:15 PM

OMG Benjamin, I thought the exact same thing, LOL. I'm like "Yeah, but most patients don't play WoW in the hospital, so when are we gonna level with each other". ha!

I tend to agree with realism though. It's a nice suggestion to forewarn patients about the procedure, especially if they are pain inducing, but in a critical situation, it isn't very practical. Not to mention the fact that if they are in the ER they are already in pain, so it's not like a bit more is going to come as a shock to them. I like to keep the conversation brief prior to a painful procedure and comfort the patient afterward. I've noticed that so long as you appropriately empathize (and treat) the patient, you aren't sacrificing any opportunities to build a rapport with them. Just my 12 cents (my two cents are free) hehe.

Posted by: Adrienne | Jan 31, 2008 8:50:41 AM


what i see is that the patient is the most valuiable text book u will ever have ,and buliding agood effective fruitefull relationship is the ultmate important thing to move forward mainly for us as student ...
thank u for sharing u're experince with us

Posted by: soso | Feb 2, 2008 2:28:37 AM

Ben. You're perfectly right and I totally agree with you.
Since I'm very curious...in Italy we call this maneuvre "Blumberg's sign". Don't you?

Posted by: mollybloom | Feb 3, 2008 1:58:38 AM

I was with the attending when a lady had an apparently perforated appendix, she was with her daughter at the ED at night and you know what a real medical enthusiast I am, I was waiting for the attending to diagnose, surgical or not surgical abdomen, all he questions asked, time for the exam, somehow tender, and rigid, the rebound tendernss done by the attending was so positive that the patient shrieked with pain and her daughter got shocked by the incident, while I victoriously smiled; GREAT!!! she really has an appendix and I'll get to see that appendicectomy. Then I saw how they looked fearfully at my smile, and immediately I thought, how much more vulgar am I going to get while I'm on in this field.
P.S: the attending went away as if nothing really happened, thanks Ben for the warning cue.

Posted by: B not ben | Feb 3, 2008 5:18:12 AM

i think i agree on that benjamin. coz valuing patient's feeling and gaining their trust on us is the real heart of our profession.

Posted by: jen | Feb 5, 2008 6:01:27 AM

Its actually a nice way to gain the confidance of the

patients which later on will make your job much easier

when discussing treatment options...Thanks for the nice


Posted by: Dr.Maryam | Feb 14, 2008 10:23:37 AM

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