Friday, October 07, 2011

The Question

There they were, little maroon flags outside three patient exam room doors. You could almost hear the game show host ask the question:
Will it be Door #1, Door #2, or Door #3?"
So I asked the medical assistant, "Who's next?" and she pointed me to Door #2.

It was a new patient with a familiar problem, one I've seen probably a thousand times before. Another day, another case. Bada bing, bada boom. Nothing to it. You would think that all cases, and all people are the same in some ways. Certainly, those managing our health care system of the future would like us to believe it's so simple: just another case of heart failure (what can go wrong?) or supraventricular tachycardia (love that one, there's NOTHING hard about that!) or maybe a few PVC's (Check). Another day, another dollar.

I suppose it would be easy to classify patients that way, after all, I'm now just a "proceduralist for the heart electrical system" in the eyes of many these days. But there is something that I always find myself looking for with each new patient I see: The Question.

The Question is the query that irreversibly connects you with the patient. It's not the details of the history of present illness or the past medical or surgical history, rather, it's The Question that makes the patient look at you in a slightly different way. It's The Question that makes them realize you're human. It's The Question that let's them know you're interested. It's The Question that is outside the rubric of medical history taking. It's The Question that keeps you coming back for more, day in and day out.

The cool thing about The Question is it's usually different for every patient. In fact, it is invariably unique to a given patient. The challenge for every doctor is finding it. And the weird thing is, you might not know you found it at first. But when someone asks you about the patient, it's invariably The Question and its answer that you recall along side their health issue. It might be a simple, "What kind of work do (did) you do?" or "What's your son doing now?" or even "Nice shirt. Where did you get that?" Nothing complicated, mind you. You hear about the job, the kids, the passions: people being people, not just an algorithm.

And the best part?

There's always (and I mean always) something new to learn.



Linda Pourmassina, MD said...

"'s The Question that makes the patient look at you in a slightly different way."

This phrase is exactly right. This is the transformation point. This is when a regular office visit becomes a more effective partnership with mutual trust/respect, which we assume is present from the get-go. There may be an invisible wall (of tension or anxiety or skepticism or insecurity, for example) in an office visit. The Question breaks it down.

As you noted, The Question can be subtle and simple, but when asked, I think it can lead to better results. Sometimes it is in the way The Question is asked, rather than the question itself. Unfortunately, discovering it can take more time than generally allotted in a typical primary care office these days. Still, it is worth looking for The Question with each and every patient.

Great post, Dr. Fisher.

Tim Hulsey, MD said...

Dr. Wes and Dr. Pourmassina are so correct! I guarantee you that their is nothing in Obama's health care reform act that addresses this aspect of medicine! Do you think Watson is programmed to make that type of connection with a patient?
I see a lot of pediatric patients, and they will frequently crack up when I, the X-Large person, will ask if I can wear their very cool, small T-shirt. "No! It won't fit you!" It lets patients know that you see a person and not a disease process.
I would add one more element to The QuestionThe Touch.
I can't state it as well as Dr. Verghese did in his TED lecture, which was the best 15 minutes I have spent lately: In today's atmosphere of the battle of the sexes, one has to be careful to do this in a professional, non-ambiguous way. The touch of the physical exam, as well as the supportive touch (a hand on the shoulder) can both help establish a connection between the doctor and the patient. I was told by an older physician to always feel the patient's radial pulse when you see them on rounds– even if their pulse rate or character isn't germaine to the operation they had the day before.
The Question and The Touch are something that Watson will never provide and the MPH/MPP geeks will never understand!

Steve Parker, M.D. said...

Two weeks ago I was working up a case of chest pain in the hospital. The patient had pre-existing coronary heart disease. I asked him The Question: "Have you ever heard of the Mediterranean diet?"

Without skipping a beat, he replied, "Does that mean I only eat those kinds of people?"

He didn't even know I collect cannibal jokes.


AnnMarie Walsh said...

Doc, this is one of my favorite posts of yours. Dr. J.M.R. has shown me that level of care. He gained my trust by demonstrating that he really cares about his patients. I have fond memories when that trust grew. One was during one of my "anorexic" phases and he saw me skin and bone at 108 lbs - far from my lowest of 94. There are other times he has shown his dedication to caring for patients. And I am sincerely grateful to any dotor who practices such compassion.