“Just listen to your patient, he is telling you the diagnosis.” –Sir William Osler
This article takes you behind the scenes of the medical interview.
When you’re done reading, you’ll know why your doctor asks certain questions, what sort of answers they’re looking for, and what they’re thinking about while you’re talking. Once you know all of this, you can learn to communicate more effectively with your doctor.
Efficient and effective communication will improve your rapport, save time, and improve the chances of your doctor making early and accurate diagnoses.
Why does your doctor need your help to make a diagnosis?
While it’s true that diagnostic technologies are advancing rapidly, many diagnoses still require expert interpretation of signs and symptoms. A web search, or even a lab test or radiographic image will not reveal the diagnosis in many cases.
Consider even some of the most common conditions treated in the emergency department – heart attack, stroke, and seizure. These are relatively simple and well understood conditions in comparison to many other more complex diseases and disorders. Patients with signs and symptoms of these conditions undergo lab testing, ECG, EEG, X-rays, CT scans, MRIs, ultrasound, and sometimes intravascular angiography. At the end of all of these tests, there is still diagnostic uncertainty in some cases.
What’s the reason for this?
To start, doctors must order the right tests. Those tests need to be performed properly. Even when we do the right tests and get accurate results, those results are not always straightforward. Tests give us data, but that data must be interpreted by humans. Sometimes results from one test conflict with another. Finally, some conditions do not produce distinguishing abnormalities on lab or radiology tests.
To make a diagnosis, therefore, physicians must understand patients’ signs and symptoms.
In fact, the most difficult diagnoses must be made by history, precisely because some conditions don’t cause measurable lab or imaging abnormalities. In addition, consider that the first sign of a disease or disorder is usually a symptom. If you have pneumonia, for instance, your first symptom might be a mild cough. The astute clinician might be able to diagnose you by history and physical before your infection is bad enough to show up on an X-ray.
The medical history remains the essential tool for making early and elusive diagnoses.
In a 1999 survey of ten internal medicine physicians, each reported an average of four diagnostic errors in the preceding year and cited the following reasons in descending order of frequency:
This list is over twenty years old, but I think it’s safe to say that these human factors have not changed.
Pay special attention to the first four reasons on the list. These are all things that patients can influence. We can help our physicians think of diagnoses they might not otherwise think of. We can bring their attention to our symptoms despite confusing or contradictory lab results. Probably the most impactful thing we can do as patients is to help the physician understand our symptoms by presenting them in a detailed and organized fashion.
What is a medical history?
A medical history is a detailed presentation of your symptoms.
A symptom is a consciously perceived sensation, such as pain, weakness, or dizziness. You can think of pain, or any other symptom, as an error message. Your medical history is a read-out of all of your error messages. It’s your doctor’s job to interpret these messages. But, the clearer the messages, the easier it is for them to find the problem.
How do doctors gather a medical history?
The best diagnosticians will gather a medical history by conversational interview. Your doctor might start by asking open ended questions like, “what’s wrong today?”
This is your opportunity to present a detailed, thorough, and succinct presentation of your symptoms.
This might seem backwards. Isn’t it the doctor’s job to ask the right questions and illicit the right information? Ideally, yes, but you can give yourself an advantage by being a good reporter.
So, how can we better do this as patients? It helps to know what doctors are looking for in a medical history. To know that, it helps to understand a little bit about how doctors are trained.
How are doctors trained to take a medical history?
In medical school, we’re taught to collect a medical history starting with a “chief complaint” followed by these features of your symptoms: Onset, Palliation and Provocation, Quality, Region and Radiation, Severity, and Timing. These features are represented by the mnemonic OPQRST.
I’ll go through each with brief examples.
This is the reason that you presented to the doctor today. If your most prominent symptom or concern is chest pain, then your chief complaint is “chest pain.” If you’ve had ongoing chest pain, but it’s worse today, you might say, “worsening chest pain.”
Describe the timing and circumstances of the onset of your symptoms.
It’s important to be as specific as possible. Give specific dates and times if you know them. If not, a rough estimate or relative time will do. It’s also helpful to give context. If symptoms started just after returning from an overseas flight, pulmonary embolism would be a concern, whereas chest pain that started during heavy lifting might make an aortic dissection the top consideration. The rapidity of the onset is also important. Pain and symptoms from pneumonia might progress gradually over the course of a few days. A pneumothorax (collapsed lung), however, can cause sudden pain in someone who was feeling fine just a moment ago.
Example: “I’ve had chest pain on and off for a month. Last night while I was running on the treadmill it started after a few minutes and worsened over the course of 20 minutes. At that point, I stopped due to the pain.”
Palliation and Provocation
Explain what makes your symptoms better and what makes them worse.
Be as specific as possible. Explain anything you’ve done to self-treat and whether or not it worked. Chest pain that improves with nitroglycerin is consistent with acute coronary syndrome, whereas chest pain that worsens with deep breathing and improves with shallow breathing is more concerning for pneumonia, pleural effusion, or pulmonary embolism.
Example: “My chest pain gradually improved over an hour when I stopped running on the treadmill, but this morning it returned when I was climbing the stairs.”
Describe the nature of your symptoms. Use the best descriptors and analogies that you can muster. Use words like sharp, dull, and achy to describe the type of pain you feel. If you can’t do that, try to liken the symptom to something you’ve experienced.
Example: “My chest pain feels like a pressure as though something heavy is sitting on top of my chest.”
Region and Radiation
Where is the pain located and does it radiate?
Describe the location as precisely as possible. If the pain is in your wrist, say that you have wrist pain as opposed to arm pain. If the pain radiates to your right shoulder blade, say that instead of saying that it radiates to your back. Upper abdominal pain that radiates to the right shoulder blade is indicative of gallbladder disease as opposed to pain that radiates straight through to the middle of the back, which is more consistent with pancreatic pathology.
Example: “The pain feels like it’s right in the middle of my chest. It radiates to both shoulders and my jaw.”
Describe the severity of your symptoms.
This is tricky because severity is very subjective.
Sometimes we try to quantify this using a 1–10 pain scale with 1 being very minor pain and 10 being the worst pain you’ve ever felt. We also try to divide severity into qualitative categories like mild, moderate, and severe. However, people have variable experiences with pain. It’s common to see patients with partially amputated limbs or deep lacerations who appear calm and report their pain as minimal. On the other hand, there are people who will report 10 out of 10 pain from a small bruise.
Many people believe they’ll be taken more seriously if they report their symptoms as severe. But, physicians see patients with a wide range of painful ailments and have a different context for pain than most people do.
Therefore, my best advice is to represent your symptoms as objectively as you can. One way to do this is to draw comparisons. For instance, you might say of your pain: “it’s worse than when I broke my toe, but not as bad as my kidney stone.” Or, you might describe what your symptoms prevent you from doing. For instance, the pain is bad enough that I stop about half-way up the stairs for a few minutes before climbing the rest, but not so bad that I would think about taking any medications for it.
Describe the time course of your symptoms.
You should aim to describe the pattern of your symptoms in time. Abdominal pain that occurs rhythmically every few minutes might suggest a bowel obstruction, whereas pain that is constant might indicate an infection. It is useful to know how long it took the pain to reach a peak and if the pain has occurred in the past.
Example: "My chest pain reached its peak within a few minutes and has been constant for an hour.”
Why is a medical history taken in this fashion?
An experienced diagnostician has seen thousands, perhaps tens of thousands of patients. An average ER doctor, for instance, might see twenty or thirty patients in a single shift, which comes out to roughly 4,000 patients in a year. Over a twenty-year career, they might see 80,000 or more patients.
When a diagnostician performs an interview, they’re primarily trying to recognize a pattern. They’re trying to match the pattern of your symptoms with other patterns they’ve encountered in the past. If they can’t make a pattern match, they can analyze the characteristics of your symptoms in the context of what they know about anatomy, physiology, and pathology. On top of this, the diagnostician is looking for distinguishing factors, or differentiators. In other words, they’re looking for something that matches with only one or a few diagnoses.
These differentiators might seem like unimportant bits of information to you, but they can make or break a diagnosis. Most pathological conditions have overlapping symptoms. Consider nausea and vomiting. These two symptoms are prominent features of problems with nearly any organ system: brain, heart, gastrointestinal, liver, pancreas, blood vessels, autonomic nervous system, endocrine glands, and more. So, nausea and vomiting alone are usually not unique enough symptoms to make a diagnosis. However, nausea, vomiting, and right upper abdominal pain that radiates to the right shoulder blade is almost always indicative of gallbladder disease. In this case, the right upper quadrant pain that radiates to the right shoulder blade is the differentiating feature that helps suggest the correct diagnosis.
So, how can we use all of this information to improve the likelihood that our physician will make an early and accurate diagnosis?
Report your symptoms as if you’re an investigative journalist.
Tell the story of your signs and symptoms. Be thorough, specific, and detailed. Leave out obviously irrelevant information. If in doubt about the relevance of a particular detail, include it, especially if it pertains to your body. Examples of important details include times, locations, ingested substances (e.g. foods, medications, and supplements), travel, contact with other people, and medical procedures.
Focus on your symptoms rather than your interpretation of your symptoms.
Report your symptoms as accurately as you can. Do not try to interpret them.
For example, if you have a burning pain in the middle of your chest and an acidic taste in your mouth after you eat, say that. You might be tempted to say, “I have heartburn.” But, heartburn is a diagnosis rather than a symptom. This may seem like a trivial distinction, but it isn’t. If you offer a diagnosis, or use a vague term like “heartburn,” you might inadvertently lead an inattentive clinician in the wrong direction. Miscommunication about symptoms has caused heart attacks to be mistaken for acid reflux.
Consider another example: If you feel as though you might pass out when you stand up, say that. You might be tempted to say that you feel dizzy or lightheaded. These terms are vague and mean different things to different people.
A good diagnostician should clarify your symptoms regardless of what words you use, but someone who is in a hurry may not.
Improve your chances of accurate communication by reporting rather than interpreting.
Assume that your doctor hasn’t read your chart or spoken to any of their staff. If they have, assume everything they learned was wrong.
Have you ever played “telephone” or “whisper down the lane?”
These are games in which one person whispers a secret phrase into the ear of the person next to them. Once the phrase makes it down the line of people, the last person says the phrase aloud. It only takes a few people before the phrase becomes adulterated, usually to the amusement of all.
Unfortunately, the same thing happens in medicine. Before you speak with your physician, you might speak with front desk staff, nurses, and medical trainees. If your physician understands the danger of playing “the telephone game,” they will start from square one to make sure they have accurate information.
Understandably, this is stressful and confusing for the patient who is not feeling well and now is being asked to repeat their story for the 3rd, 4th, or 5th time. The repetitive questioning may not be good customer service, but it’s still important to tell your story in full to the physician who is responsible for your diagnosis. If you don’t tell them something directly, assume they don’t know it, or worse, that they have misinformation.
What are other factors that affect the ability of your doctor to properly diagnose your conditions?
The nature of your relationship with your physician is important.
If you lack rapport with your physician, they won’t have a good context in which to understand your symptoms. It helps to find a doctor and build a relationship with them by engaging in preventive care and keeping regular appointments.
However, if you become too friendly with your physician, they could lose objectivity or fail to look deeply into issues that might be embarrassing or sensitive. This is one of several reasons that state medical boards frown on physicians caring for their own families.
Your ability to be honest and share private details is important.
It’s common for patients to omit, hide, and manipulate information out of embarrassment, privacy concerns, or simply because they believe it’s irrelevant. If your doctor is asking a private question, a good assumption is that it’s relevant to the diagnostic process. Out of your own self-interest, it’s good to answer the question honestly. If you’re suspicious of a line of questioning or hesitant to share certain information, ask of its importance. Usually, the physician can explain quite easily why certain information is important. If they can’t, it might be time to find a new doctor you can trust.
What else can you do to improve the chances of receiving a timely and accurate diagnosis?
You can teach your physician.
Patients often research their own conditions. After a certain amount of research, it’s not only possible, but probable, that you have learned at least one thing about that condition that your physician doesn’t know. Don’t be afraid to politely show them what you’ve learned. A good physician will want to learn from you. If your physician is resistant to learning from you, find a new one.
You can request a more thorough physical examination.
The physical exam is becoming a lost art. The pressures of clinical practice and the availability of testing has resulted in many physicians spending less time and effort on physical examination. Don’t be afraid to ask your physician to listen to your heart and lungs and to examine your abdomen if they’ve neglected to do so.
As unpleasant as it is to have a genital or anal exam, if you’re having a problem in that area, allow an examination. Physicians know these exams are sensitive and often hesitate to perform them, just as most people would prefer not to have them done. Nonetheless, they’re necessary in some cases. I know of several missed diagnoses that occurred because nobody looked at a sensitive body part. The physician should have a chaperone (usually a nurse or medical assistant) in the room for the safety of both parties.
You can and should request copies of all of your medical records including notes, test results, and radiology images and reports.
In the age of the electronic health record, documentation is voluminous. For the most part, electronic records improve patient care by making it easier to review, search, and share data. However, the more notes and data in your record, the higher the likelihood that small errors and abnormal tests go unnoticed.
Request all of your records and test results and review them yourself. Have your trusted primary physician review all of your records as well.
You can and should seek second and third opinions.
No physician should be offended by your desire to seek additional opinions. Medicine is challenging. Lisa Sanders, MD, consultant for the show House MD and writer of a NYT column called “Diagnosis,” has said that, “the person most likely to make the diagnosis is the person who has seen it before.” You might have the best most thoughtful and caring physician in the world, but if they’ve never seen a case like yours before, they might be unable to make the diagnosis. Seeing someone else might get you the diagnosis immediately simply because your case is familiar to them.
What if you have a complicated case that nobody can diagnose, what then?
First, you should seek to establish a relationship with a primary care physician who cares deeply about their patients and their work. It’s excellent if you can find a brilliant physician with the best training and the most experience, but what you really want is someone who will stop at nothing to help you find answers. One way to find this is to look for a physician who runs a Direct Primary Care Practice, or DPC for short.
Of course, most primary physicians are not in DPC practices, and many of them are great too. But, DPC practices are unique for a few reasons. The DPC business model involves paying a monthly fee, usually for unlimited care. By setting up the practice this way, and by eliminating overhead, these physicians usually run practices with several hundred patients (or less) instead of several thousand. This allows them to establish good relationships and to spend a lot of time with you. Last, because the practice is theirs, they are much more likely to be motivated to take ownership for the quality of their work. The problems that I alluded to in this article are less likely to occur if you belong to a DPC practice. On the average, you’re likely to have longer appointments, better access, more attention, better relationships, better communication, more careful record keeping, and close follow up.
What else can you do if you have a truly elusive diagnosis?
There are a few resources available to people who can’t get a diagnosis. You can pay to crowdsource your case on crowdmed.com. You can travel to New York City and pay to have a team of experts research your case at Focus Diagnostic Medicine or for truly unique cases, you can try to submit your case to the Undiagnosed Diseases Network.
If you’re fascinated by the diagnostic process like I am, you might enjoy reading these books and columns:
- Dr. Lisa Sanders’ NYT column: Diagnosis
- Sandra G. Boodman’s Washington Post column: Medical Mysteries
- The Case Records of the Massachusetts General Hospital in the New England Journal of Medicine
- Sanders, Lisa. 2019. Diagnosis: Solving the Most Baffling Medical Mysteries. 1st edition. Crown.
- Groopman, Jerome E. 2008. How Doctors Think. Reprint edition. Mariner Books.
- “One Doctor: Close Calls, Cold Cases, and the Mysteries of Medicine: Reilly M.D., Brendan: 9781476726298: Amazon.Com: Books.” 2021. Accessed March 20.
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