A Country Doctor Writes:

When a patient presents with a new symptom, we quickly and almost subconsciously create a hierarchy of diagnostic possibilities. I pride myself in my ability to effectively share my process of working through these types of clinical algorithms.

But sometimes I seem to get nonverbal clues of dissatisfaction or simply no reaction at all to my eloquent reasoning. And only then do I remember to ask the important questions, “do you have any thoughts on what’s causing this” and, most importantly, “what’s your biggest fear that this could be”.

It doesn’t matter how brilliant a diagnostician you are if a patient with less medical knowledge than you has a thought, fear or hunch that diseases and symptoms work in ways that don’t make sense to you.

An uncle may have had a burning sensation in his nose minutes before a stroke, so this symptom may seem like a much more obvious harbinger of disaster to your patient than it does to you. How would you know, if you didn’t ask, what the number one question is that your patient wants the answer to?

We are often so focused on our own thinking process, especially with our time pressures and the bureaucratic requirements of medical encounters these days, that we risk forgetting our patients may not think the way we do.

Of course, sometimes things work the opposite way: The patient may think they just have something simple, like the woman I saw with throat pain who ended up getting a cardiac stent for a major coronary blockage.

So it isn’t always obvious when we need to ask the “biggest fear” question. That’s a judgment call that requires paying attention: Watch your patient’s facial expressions and body language, listen carefully to their words and the character of their voice.

Basically, start by ignoring what the listed chief complaint is, ask an open ended question and then shut up and let the patient speak uninterrupted so you can listen and observe.