The Art of Asking: What Else is Going on?

Walter Brown’s blood sugars were out of control. Ellen Meek had put on 15 lbs. Diane Meserve’s blood pressure was suddenly 30 points higher than ever before.

In Walter’s case, he turned out to have an acute thyroiditis that caused many other symptoms that came to light during our standard Review of Systems.

Ellen, it turned out, was pretty sure her husband was having an affair with one of his coworkers. And, since this wasn’t the first time, she was secretly working on a plan to move out and file for divorce. She admitted she’d always had a tendency to stress eat.

Diane’s daughter had just announced that she was pregnant by a man she wasn’t sure wanted to be around in the long run.

How do we know whether a patient’s subjective symptoms, laboratory values or even their vital signs are caused by their known medical conditions, a new disease or their state of mind?

We are often tempted to proceed down familiar tracks and tackle seemingly straightforward problems with medications: More insulin would take care of Walter’s blood sugar. Ellen could use a couple of months of phentermine. Diane needed a higher dose of lisinopril or perhaps some hydrochlorothiazide.

As Sherlock Holmes said, “there is nothing more deceptive than an obvious fact”.

There are all kinds of algorithms and guidelines that are supposed to inform clinicians in situations like these, but I wonder how often they are helpful and how often they might actually cause harm.

Medicine is part physiology and part psychology. Are we giving both aspects of our craft the attention they deserve? And, of course, do we make choices and treatment decisions according to probability or by time available to stay on time in our clinic schedules?

Asking “what else is going on” can open up the dreaded, proverbial floodgates, can of worms or Pandora’s box. We don’t have all these cliches in our language for nothing.

Do we avoid asking the questions that will reveal the real answers we need in order to help our patients, or do we dare to?

4 Responses to “The Art of Asking: What Else is Going on?”

  1. 1 Henry Hochberg February 22, 2021 at 9:29 am

    The “system” doesn’t value our deeper probing or compassion. The patients do. Can we work for both at the same time? For some of us yes, for some no.

  2. 2 johndykersmddykerscom February 22, 2021 at 2:11 pm

    You are likely painfully familiar with the saying “If you did not record it, you didn’t do it” that the risk management people and the attorneys are fond of repeating. I contend that this is prima facie not True. There is so much that passes between us and a patient in an in person visit that is subliminal. We may not consciously realize what has been done, much less be able to record it! If we recorded all the nuances we feel in an encounter we could see one person a day!
    I hope the schedule you want to keep is your own, not one imposed by the hospital that owns your practice.

  3. 3 johndykersmddykerscom February 22, 2021 at 2:14 pm

    Our next challenge/opportunity is to transfer this intimacy to telemedicine visits.

  4. 4 johndykersmddykerscom February 22, 2021 at 10:02 pm

    Dear Dr. Hochberg, MCRA would enable us to work for patients and system.
    Dear Dr. Gee,

    Thank you for a comprehensive look at Medicaide. How would you enjoy having the Medical Care Restoration Act solve the dilemmas you addressed?

    Dear Dr. Kocher,

    Thank you for such a thorough, insightful, and pointed analysis of the chaos that is driving us all crazy.

    Following is a letter to colleagues who also understand.

    Dear Dr. Steinbrook,

    You and Drs. Katz and Redberg did a magnificent work in outlining the deficiencies and stresses of health care in America. Patients and physicians and payers are bamboozled by the chaos. The administrative leeches that siphon billions annually from the health care of Americans will steadily disappear with the Medical Care Restoration Act. Compared to M4a, the Medical Care Restoration Act is smoother, more effective, Voluntary, Universal, improves quality of care, decreases cost, moves economic power, authority and responsibility, to a Dr/Pt relationship which is healing, and away from hassle bureaucracy of government, insurance or hospital interfering with healing. MCRA diminishes defensive medicine, encourages learning, preventive medicine, and patient care; restores non monetary rewards to practice of medicine and surgery, requires physicians to earn their keep, restore honor, affection and effectiveness to the healing professions. MCRA text is 10 pages 5×7 and 16 font in Chapter 2 of “The Price of Eggs Is Down”. I think you will appreciate other chapters too.

    I hope you will add your voice to permissive legislation that does not require repeal of ACA.

    John R. Dykers, Jr. MD for CV and bio

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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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