What Is It?
Many of my writings concern ways in which my training did not prepare me for the realities of medical practice. This is no exception.

In medical school, we were taught to begin a patient interview with a completely open ended question like "Tell me what brings you in today" or "So, what's been bothering you?" We are then to listen to the entirety of the monologue that follows before asking more specific questions, like "how long ago did the cough start?" This approach is supposed to give the patient an uninterrupted opportunity to tell her whole story in her own words.

This approach frequently fails, and it frequently fails the same way. It fails because many patients have no idea what a doctor needs to hear and because of the singular impersonal pronoun "it".

Here is a typical encounter.
Me: So, tell me why you're here today.
Patient: Well, I'm feeling pretty sick. It started when I was over at my sister-in-law's house, and, you know, the whole family was there, and for all I know someone there had it first. And we all overate, of course, and that night is when it started. And first I thought it might have been because of her cats, but I'm at her house all the time and it's never happened before. Anyway, the next morning it was much worse. I felt really bad. So I took all this over-the-counter stuff, and during the day it got a little better, so I figured that I'd get some sleep and in the morning I'd be fine. But in the morning I was much worse and that's when I figured that it couldn't have been her cats. Then, even though I was really miserable, I thought I'd wait it out a couple of days because, you know, these things sometimes just get better on their own. But each day, I felt worse than the day before, and I finally called your office.

Note how well I followed my training. Note also how I was punished for this. The patient believes that he is telling me lots of information, and he’s certainly talking a lot. He’s telling me a whole lot about his life at the time of his illness, but he’s telling me nothing that will help me diagnose or treat this illness. What he doesn’t know, or hasn’t slowed down enough to consider, is that what I really need to hear to diagnose his problem is the symptoms he’s having. He hasn’t mentioned a single symptom so far. A cough, a fever, and loss of appetite are all symptoms, while being with the whole family, taking over-the-counter medicines, and blaming the cats are not. Pretty simple, no? You’d think so, but so far I don’t even know which organ system he’s having the most problems with. Is he having digestive problems? Respiratory? Urinary? Your guess is as good as mine. He never actually refers to any of his symptoms or his illness except for with the word “it”.

At this point, I’m looking at the patient with an increasingly puzzled look and my forehead is more wrinkled with every unhelpful sentence. I haven’t recorded a single word yet in the chart, since he hasn’t said anything worth recording. I’m trying to figure out how to redirect this runaway train with a more focused question. Unfortunately, this pause is frequently misinterpreted as an invitation to continue.

Patient: So after I called your office, I called my sister-in-law to tell her how bad I felt and she said that two years ago she had the same exact thing and that her doctor had to try three different medicines before she got better, but she’s in an HMO, so I’m sure you’re smarter than that. Anyway, she agreed that I should see you right away, and she was a little offended that I even thought it was her cats, but I felt too sick to be embarrassed.

Then, frequently, the patient will close his information-free soliloquy with a question.

Patient: So, do you think it could it be Strep?

What? Not only have I not examined you, but you’ve just used up a quarter of the visit telling me nothing, and now you’d like me to take a stab at the diagnosis!? That usually comes at the end of the visit. Do I think it could be Strep? Sure. It could also be schizophrenia or colon cancer. How ‘bout you throw me a bone here and actually let me in on the big secret. What is it? Sore throat? Vomiting blood? Headache? Voices telling you to kill the President? Am I getting close?

Early in my career I would at this point fantasize about leaping out of my chair and knocking the patient to the floor while screaming “WHAT IS IIIIIIIIIIIIIT!!?” I was mostly restrained by the certainty that the California Medical Board frowns on that sort of behavior. Eventually I learned through trial and error ways to get the interview back on track.

Me: You haven’t told me what’s actually bothering you. What’s “it”?
Patient: I thought you were gonna tell me.

SECURITY! Have this man removed. Ahem. Sorry. Let’s try again.

Me: I mean what actual symptoms were you having?
Patient: Symptoms? Oh, mostly my stomach really hurt.

HALLELUJAH! The clouds part and the angels sing. At this point the actual substance of the visit starts and much health care is delivered, but for that part I can actually rely on my training. - served up by Doctor Bean @ 6:31 PM