Marble Dinosaur Egg: “What’s Your Concern?”

Another in a continuing series of the Dinosaur version of “clinical pearls”. Okay, so the series consists of three other posts, all in 2007:

1. Medication adherence
2. Biliary symptoms
3. Extending your scale

But hey. Here’s another.

One of the most important things we teach medical students is to elicit any specific concerns patients may have about their conditions. Many of them get pretty good at it, though by the time they get through the rest of their training, perilously few of them — now that they’re called “attendings” — are still doing it. Yet I maintain it’s still one of, if not THE most important thing you need to elicit from the patient. Here’s why: if you don’t address whatever the patient is really worried about, that patient is not going to be completely satisfied with the encounter.

The major reason doctors stop trying to elicit this critical information is their perception that it takes too much time. They believe broaching the topic will open up a can of worms, as the patient drones on and on about all kinds of intangibles.

Wrong.

Actually, it’s as quick and easy as it is important. And here’s the kicker: it’s your chance to look outrageously smart, since the vast majority of the time, the patient is worried about something so far-fetched and different from everything in your differential that addressing it — and easing the patient’s real concern — is quick and straightforward.

Here’s how to do it: last question of the interview (phrasing options, depending on the presenting complaint, the seriousness of the differential, and the sophistication of the patient):

• What’s your concern?
• Is there anything specific you’re worried about?
• What did you find when you googled this?

Some examples:

A patient rattling off symptoms of MS as if he’d read the textbook:

• “What did you find when you googled this?”
• “I didn’t.”
• “Well, is there something specific you’re worried about?”
• “Yes, a brain tumor.”

Piece of cake to reassure him that’s not what it was. Interestingly, once he’d heard that, he took the possibility of an MS diagnosis totally in stride.

Next: an older woman presenting with a complaint of her arm shaking, with a story very worrisome for partial seizures.

• “What is it you’re worried about?”
• “Parkinson’s disease.”

Last thing anyone would think of, given the specifics of the history. But very easy to explain why. Of note, the (young) neurologist she saw never asked if she had any specific concern, and was floored when I told him she was worried about Parkinsons. Never occurred to him.

Easy ones:

Sore throat, stuffy nose, cough in an adult. No fever.

• “What’s your concern?”
• “I want to make sure it’s not strep.”

Thirty second explanation and everyone’s happy. You could go on for half an hour about upper respiratory infections and viral pharyngitis, but if you never said, “Strep” (preceded by “not”) that patient would leave unsatisfied.

Tough ones: (mainly when there’s the potential for something serious, and the patient knows it)

Bloating, weight gain, early satiety, urinary symptoms for two to three months in a 50-something woman:

• “What are you afraid it is?”
• “Some kind of cancer.”

My answer: “That’s definitely a possibility. Let’s do everything we can to find out as soon as possible.”

By and large, though, when you take the time to ask something simple along the lines of “What’s your concern?” patients will come up with things that are so ridiculous from a medical standpoint that it would never occur to you to specify that that’s NOT what they have. The only way you’ll find out is to ask.

Do so.

It takes hardly any time at all, and the benefits in terms of both patient satisfaction and looking really smart are significant.