In the previous post we talked about using proper greetings and explanation to win rapport and trust. We talked about a 16 month old with scalp pain that could not be localized. Often efforts at rapport and trust do not work. What do you do next?

For straightforward presentations there is nothing wrong with physical restraint and looking in the ears against resistance etc. William Carlos Williams has a short story “The Use of Force” where he makes this into a morally ambiguous act about subduing another person. Nonsense! Tell the child that you help kids feel better and you are going to check for owies. If you see resistance, have the parent hold the kid and proceed.

But sometimes the presentation is not clear and we need skill in winning a child’s compliance.


Use objects in the room for distraction but these do not always work. Blowing up a glove into a balloon and drawing a happy face works pretty well. Having the glove talk to them is even better. Smartphone photos are great, the child is usually mesmerized.


You might tell them a story; “there is a mouse on the loose in here, have you seen the mouse?” The mouse story, if it works, is good because the mouse can run to wherever you want to examine. “Let me check your ears for the mouse.”

Other forms of play might be to state your commands in ways that captivate the child’s imagination; “pant like a dog” elicits better compliance for oropharyngeal examination than “say ah.” For the abdominal examination, say “let me check your abdomen and see what you had for lunch.”

Take Home Points:

-Use distraction to help localize tenderness

-Use imaginative play to make the examination more fun



A 16 month old presented with pain in the scalp. The examiner was not able to localize it further because the child was uncooperative and crying. What now?

To localize pain in a toddler, we need the child’s cooperation. There are three ways to achieve this. The first approach is to win rapport and trust.

Introduction: I start with a proper introduction to the child on eye to eye level. If they are old enough to understand, I might say “I am the guy who fixes owies.” (sometimes followed by a comical search for “owies” well away from the affected area).

Non-clinical touch: The first touch should be non-threatening. I sometimes do a formal handshake for humor, or a pat on the back, or a light touch of the foot as I say hello.

Say his or her name:

Use his or her first name frequently to enhance familiarity.

Anticipatory Guidance

Demonstrate the exam on yourself or on the child’s mother first. This is really important with the otoscope. The best model is a cooperative older sibling.

If this works, great! Sometimes it does not. Read my next post for the second approach, on distraction and play.

Take Home Points:

-Treat kids like little adults: With respect. Introduce yourself, use an age-appropriate physical greeting, and address them by their name.

-Explain things in advance: model the examination on yourself or a family member.


An elderly patient is brought by family for confusion. You wonder whether this is delirium, or whether dementia may have developed. As covered in a previous post, dementia is defined by a deficit in memory as well as one other cognitive function. You can easily test for 3 item recall and clock drawing. But for those tests to be valid at all you have to exclude delirium. The hallmark of delirium is inattention.

Have them count the months backward, starting with December, to see if they can maintain attention. This is 83% sensitive and 90% specific for delirium.(O’Regan JNNP 2014) Interestingly, the addition of confirmatory tests (CAM) to improve specificity worsened sensitivity to 62%. Of course, delirium is not a binary event but exists across a spectrum. So some of the deviation from perfection could merely indicate a different location on the spectrum of illness severity. In light of its simplicity and ease of use, I recommend using months backward in your ED delirium screening. This is not a gold standard but does contribute value in raising or lowering the probability.

You assess months backward and the patient goes no further than November. You suspect delirium, and are relieved when you discover a UTI. You give the family assurance that the confusion will improve, though she will need to see the family physician in follow-up to confirm cognitive function.

Take Home Points

-Delirum, in the ED, is identified by inattention

-Have the patient count the months backward as a fast bedside screening test


It is possible to adequately address a chief complaint but not identify or meet the patient’s concerns.

Agenda setting is defined as that process of the medical encounter where the doctor and patient agree on the plan for the visit. If agenda setting is not done, it defaults to whatever the doctor thinks is needed, and sometimes patients feel their concerns were not addressed.

Interpersonal skills are often portrayed as something we do in addition to our normal duties. The implication is that it would add time demands. But a group of researchers reported that certain interpersonal skills actually saved time.(Mauksch Arch Intern Med 2008) Those skills included rapport building, empathy, and agenda setting.

How do we conduct agenda setting? Here are two scripted phrases:

“What concerns you the most?” (addresses the patient’s fears)

“How can I be of most help to you?” (addresses the patient’s goals)

Another way of asking the second question is “what is your goal for this visit?” or “what would you most like to see accomplished?”

When we ask those sorts of questions we are identifying the patient’s concerns and needs, and setting the course for a more effective patient encounter.

Take home points:

-Set the agenda for the visit collaboratively with the patient

-“What concerns you the most?”

-“What would you most like to see accomplished today?”