Stories from the Stethoscope: September 2020

About two years into my private practice career, I was very proud of the reputation I was developing.  A colleague of my mother decided to bring her husband to see me to diagnosis a long-standing issue of back pain.  Kevin was middle-aged with a collection of well-controlled medical issues.  He walked into the office with his wife, a large manila folder of data, and frustration in his eyes.  I shook both of their hands, welcomed them and said, “How can I help you today?”  He said I have been to my primary, the Emergency Department, a Urologist, an Orthopedist, and a Rheumatologist.  What are you going to do they have not done?

Hearing and seeing his frustration, I looked in his eyes I said, “I am going to listen to you.” I sat back in my chair, made myself visibly comfortable and let him explain his two-year journey.  As I listened, I noticed a theme that I wanted to explore.  After he finished, I began to ask my questions.  I went through the time-honored process all medical students are taught.  I asked the cardinal symptoms that all good history taking recommends.  These include, location, quality, severity, duration, timing, alleviating or aggravating factors and any associated symptoms. 

After hearing Kevin, I realized he was really reporting back pain on his right side that was worse about 1-2 hours after he ate a heavy meal.  This was not a classic location of the pain, but the timing, duration and aggravating factors all fit.  I opened the folder and combed through the data with him.  Labs, x-rays, MRI’s all completed.  No one considered that this could be his gallbladder.  I shared my thoughts ordered an ultrasound and eventually sent him off to the surgeon to have is gallbladder removed. His pain went away, and the family was very appreciative.

All I did was listen and make sure I did not forget to ask the right questions.  It seems easy doesn’t it?

As my patient case load became heaver and I had less time to spend with patients I was concerned about how I could duplicate this encounter.  I decided to do a few things.  The first was I always say, “How can I help you today.”  Often my efforts need to be placed on the active issue we can address at the time of the appointment.  If too many concerns are raised at once I try to redirect the patient to focus on high priority tasks. Let’s tackle these today and work on the rest in the near future. The second thing I do is let my patient speak uninterrupted for at least 60 seconds.  I want them to feel comfortable and if I start asking questions too soon, I may lose their confidence which will impact the provider-patient relationship.  This has helped my focus and not stress that I have only 15 minutes to fix everything.  Listening is an acquired skill.  Listening takes time, effort and many times will power.  I often have to remind myself of this.  It is even more evident now that social media and smart phones have created immediate gratification and access to answers, that often creates frustration if we don’t get answers right away. If you pay close attention you will realize that sometimes listening is the only thing you have to do.