Doctors, make sure you know what’s really bothering your patients l Expert Opinion
Physical symptoms are important, but they may not point to the worries that are keeping a person up at night.
Throughout my career, medical students have asked me what I think is the most important question to ask patients during an office visit. For a while, my favorite response was, “Tell me the story of what brought you in to see me today.” It is open-ended, shows sincere interest, and encourages patients to explain their symptoms in their own way.
While I still use that prompt routinely, I have added a new question that is even more revealing: “What are you most concerned could be wrong?” Beyond the symptoms and sequence of events, which will help lead me to the correct diagnosis, this question gets at what could be an even deeper issue.
Last week, a man in his 60s came to the office after five days of abdominal bloating, nausea and diarrhea. He was otherwise fairly healthy with high blood pressure well-controlled by medication. His new symptoms were beginning to resolve with a bland diet and increased fluid intake. The physical examination was normal, and I reassured him that this was most likely a “stomach virus” that was going away on its own. Then I asked my favorite question, and was taken aback by his reply.
“Well, my brother-in-law has pancreatic cancer, which all started with bloating and stomach cramps. Having witnessed his suffering, I’m absolutely terrified of getting it.” He told me that he was reluctant to bring this up because he would feel embarrassed if his worries were unfounded. I said that his concern was very understandable, and we spent a few minutes discussing pancreatic cancer and how the sudden onset of his symptoms and quick improvement did not raise for me any suspicions of cancer. These were probably the most important few minutes of his visit, and he left visibly relieved.
Worrying about serious illness is something many of us can appreciate, especially with abundant media available, which may heighten fears. The specter of COVID-19 and the unpredictable way in which it may cause life-threatening illness has made such fears more common and relatable. It is reasonable to expect that your physician will address your most profound concerns, no matter how unrealistic or irrational they may seem. I strongly encourage you to raise them, even if you are not directly asked.
A strong doctor-patient relationship hinges on clear communication in a setting that feels physically and emotionally safe. If you do not feel comfortable disclosing your greatest worries at the doctor’s office, it is worth exploring why. If you think there is something your doctor or office staff might improve, then take every opportunity to provide feedback, which most medical practices now take very seriously. Acknowledging and addressing worries is as much a part of care as is diagnosis and treatment.
Now, when medical students come to our practice for their family medicine clerkship, I don’t wait for them to ask me about my favorite patient interview question. I share with them that there are always two important diagnostic challenges in every visit: diagnosing the disease, and diagnosing the concern. No visit is complete without addressing both.
Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices at Penn Medicine.