The Art of Listening: Beyond the Chief Complaint

A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.

One patient may have a brand new worrisome problem we must start evaluating from scratch, while another is just coming in for a quick recheck. Those are diametrically opposite tasks that require very different types of effort.

Some visits require that test results or consultant reports are available, or the whole visit would be a waste of time. How could you possibly plan your day or prioritize appointment requests without knowing more specifically why the patient needs to be seen?

So, as doctors, we usually want our daily schedules to have “Chief Complaints” in each appointment slot, like “3 month diabetes followup”, “knee pain” or “possible dementia”. That helps everybody in the office plan their day.

I always bristled at “not feeling well” because that is too nonspecific. After all, that could be something that would have been better handled with a 911 call. But there is also a danger in being too simplistic when classifying what people come in for. We like to pigeon hole clinical concerns a little too quickly sometimes.

I had such a situation recently. It hinged on the patient’s choice of one common word over another.

A middle aged woman wanted to be seen for “throat pain”. It was halfway into a busy afternoon and between the three providers in our office, we had no openings to offer her.

Autumn asked me, “can we fit in a throat pain today? I’ve got Nicole Bamford on hold”.

“What kind of throat pain?” I asked. “You mean just a sore throat?” I was working on refills between patients. Autumn asked the patient to elaborate while I continued to work.

“She says she can swallow all right but for the last few days she gets this pain in her throat every time she does anything heavy.”

“Does she have pain right now?” I asked.

Autumn checked. “No.”

“Have her come right over.”

Nicole had no cold symptoms. She had normal vital signs. She had a two week history of throat and occasionally jaw or ear pain after minor exertion, never more than a few minutes. Sometimes she felt a little short of breath at the same time.

Her exam and her EKG were normal. She was a smoker with a family history of heart disease.

“Call the ambulance, 54 year old woman with new angina, no pain right now. I’m calling the ER”, I told Autumn after I explained my assessment to Nicole. She had seemed to accept my diagnosis of unstable angina without questioning and also my recommendation that we get her to the hospital by ambulance without expressing any sign of surprise or emotion.

When I saw her in followup after her ER visit, transport to the tertiary care center and successful stenting of a 95% blockage of one of her coronary arteries, she told me “I thought you were crazy”.

I thought to myself that this could have played out very differently if the nuance between “throat pain” and “sore throat” had gone unnoticed.

It’s nice to know what a patient is coming in for, but that isn’t necessarily the diagnosis they leave with.

1 Response to “The Art of Listening: Beyond the Chief Complaint”

  1. 1 Laurie Thomas MD November 18, 2020 at 9:44 am

    Great catch. This story illustrates the power of clinical experience. But also of the patient’s thoughtfulness in describing her symptoms. How easily it could have been missed if she just said “sore throat.”
    But it also could have been missed because of the way EHRs have restricted the way we practice now. For that reason (and others) I stopped using one. My patients’ records are in old fashioned paper charts. Another thing that allows me to focus on medicine instead of coding is I stopped taking insurance. I spend 100% of my time and energy on medicine. Medicine is interesting and fun again!

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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