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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.

Stewardship: We Worry More About the Environment than Our Own Bodies

Sooner, rather than later, we will be driving electric cars because of the environment. We use energy efficient light bulbs and recyclable packaging for the same reason. And there is a growing debate about the environmental impact of what kind of food we produce and consume. But I still don’t hear enough about the internal impact on our own bodies when we consider stewardship of natural resources.

Our bodies and our health are the most important resources we have, and yet the focus in our culture seems to be on our external environment.

Just like the consumption culture has ignored its effect on our planet in favor of customer convenience and business profits, it has ignored the effect it has had on the health of the human beings it set out to serve. And just as we now are fearing for the future of our planet, we ought to be more than a little bit concerned about the future of the human race.

But, just as we really can’t expect the corporate world to lead the environmental effort, unless we can engineer a way for them to see profit in doing that, we cannot expect it to lead any kind of effort to make the population healthier. That is something that has to start with the individual.

We all need to take responsibility for our actions, large and small, external and internal. Idling your car to warm it up before your morning commute is bad for the environment and eating corn flakes, instant oatmeal or pop tarts for breakfast is bad for your body. And, for lunch, I see cars lined up, idling, at takeout restaurants that don’t have fruit, vegetables or unprocessed grains on their menu. And just think of the soft drinks that come with those meals.

Driving to make a short, nearby errand is bad for the environment. Choosing not to walk that distance on foot is bad for your body.

The one good thing that may have come with the Covid pandemic is that people are cooking and eating more at home and I hear there is a renewed interest in growing your own vegetables. Someone wrote recently that in some way our physical world has gotten smaller and more important to us while the nation and the world have come to feel almost virtual.

Maybe that offers some hope that we will pay more attention to our own health and our own habits.

If we don’t, the chronic diseases plaguing the industrial world will dominate our lives in ways that one day will make the environmental disasters seem irrelevant to the growing majority who will suffer from the failures and breakdowns of their own bodies.

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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