It’s the very first question to ask on the History & Physical, a question deceivingly simple that sets the stage for the whole clinical encounter. The chief complaint. “Can you tell me why you are here today?” “I see the nurse note says [blank], is this why you are in our clinic today?” It sounds straightforward, the patient schedules an appointment at a doctor’s office with an intention of being diagnosed, treated and/or followed-up for an ailment. In the family medicine clinic, most patients had a time slot of 15 minutes for an attending to perform the history and physical and figure out the assessment and plan. With a simple cold or hypertension follow-up chief complaint, I knock on the door feeling relaxed and assured- this should be an uncomplicated visit with 15 minutes as more than enough. Time after time I am wrong.
I walk in the door, start to ask details about the cough the patient told the nurse was her chief complaint. “I don’t know if it’s because of the cough, but I also noticed I get more tired recently. And I have this back pain that just won’t go away.” One chief complaint has multiplied to several. Each complaint could be separate problems or different symptoms of the same underlying cause- I gather more information to try to sort it out. “When did your cough start?” “How long have you noticed that you have been more tired?” “Does your back pain get worse when you walk?” After my haphazard interrogation, I hesitate before moving on to the Review of Systems. This is the part where you ask the patient a laundry list of head to toe symptoms. Do I really want to risk unleashing a Pandora’s box of more complaints? I had heard residents call patients who say “yes” to every symptom on the RoS “pan-positive”. Stereotypically the pan-positive patient was a middle-aged Hispanic lady, which my patient was.
“Ok now I’m going to go through a list of different symptoms. Please tell me yes or no to whether you are experiencing any of these.” As I guessed, she is a pan-positive patient. Sleep changes, yes. Appetite changes, yes. Generalized weakness, headaches, pain everywhere. I was feeling resigned. Some people really need to suck it up and deal with a little pain or tiredness. Are people really expecting doctors to prescribe a magical pill to instantly make them feel 100 percent?
I trudge on. When I ask my patient if there are any new stressors, she looks down and quietly tears appear at the corners of her eyes. Her voice quivers and she says, “Since my husband left me a few months ago, I just feel sad all the time”. She wipes her tears. “I can’t focus at work, and I don’t enjoy any of the activities I normally do. This cough just won’t stop either, and the back pain makes it painful to even sleep. I don’t know what to do.”
With a busy typical day in clinic- the 15 minute visits, clicking through EMRs, studying for the shelf exam during any downtime, it is easy to be tempted to minimize my patients’ complaints and stereotype their personalities, focusing on only trying to “fix” the chief complaint. But establishing rapport and empathetically listening to the patient’s concerns can make all the difference. This way we can treat the patient and not the just the chief complaint.
