The Talkative Patient With Many Symptoms
Dr D: Let me give you a heads-up before you go in this room. She is a bit talkative. I want you to realize that you’re not going to be able to fix everything. OK?
MS3: Yeah, I guess.
Dr D: I want you to limit the amount of time you spend in there. So, I might even knock on the door and pull you out no matter what you’re doing. Shoot for coming out in 15 minutes, OK?
(20 minutes later)
Dr D: So how did it go? What brings Mrs Smith in today?
MS3: Well, she had a long list of concerns. I have them right here. I promised her we would go over them all. She has some epigastric pain, worse at night. Hasn’t awakened her. She has been having what she thinks is a sinus headache, with mild pressure over her cheeks and forehead, intermittently over the past week or so. And she continues to have this odd burning feeling in her feet. It sounds like the description is identical to last time you saw her. And her high blood pressure isn’t great today at 154/94. But she says it’s because she had macaroni and cheese last night, she did not take her medication today because she was coming to the doctor, and it always goes up when she’s here. She’s concerned that she might have diabetes, because she’s thirsty. I tried to reassure her that it’s hot right now, and she might be dehydrated.
Dr D: OK. That is a long list. We’ll go back in and see her together in a second, after I hear a little more. When we go back in, watch me, and give me feedback after we’re done. I like Mrs Smith a lot, and I do have to redirect her a good bit.
(after the visit is over)
Dr D: So, what did you notice?
MS3: Well, you tried to get her to pick the most important reason for the visit.
Dr D: Yes, how did that go? She never really picked a reason, did she?
MS3: (smiles) That seemed to help her focus her concerns a little. And you explained to her that we only had time to focus on a couple of her concerns fully today. And you thought that she should come back in 2 weeks to cover some other issues.
Dr D: Right. And that worked a little bit?
MS3: Yeah. I think it helped.
Dr D: So I used a couple of techniques to help organize her concerns. What else was I trying to do, besides moving the visit along?
MS3: I think you were trying to make sure you addressed at least a couple of her problems well.
Dr D: By fully focusing on them. OK. And I was also trying to have her feel that she didn’t need any new symptoms to come see me. I made her an appointment in a couple of weeks to spend some time together, and to reconnect with each other, without her having to convince my front desk personnel that she is “sick enough” to be seen. But, one more thing. How did it feel when you were with her? During the first part of the interview?
MS3: I felt kind of under water. Confused.
Dr D: Overwhelmed?
MS3: Almost drowning.
Dr D: Exactly! How is your feeling connected to her situation?
MS3: I don’t understand.
Dr D: Well, we often pick up feelings from our patients. And these feelings are like physical exam findings that we pick up.
MS3: Oh, well, I guess she might feel the same way I do—overwhelmed?
Dr D: So the way we feel often mirrors how the patient feels inside. You were picking up on how she feels —confused and overwhelmed. And we’re not just responding to each item on her list. We are trying to respond to the diagnosis, not the symptom. Our job is to figure out why she has a list—what is the true or inherent meaning of the list, not just what each item on the list indicates.
D. Todd Detar, DO, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
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