1. Family medicine is in a state of crisis
2. Family doctors are the foundation of the health care system. Investing in family medicine means better health outcomes for British Columbians.
3. A family doctor’s work doesn’t end when the last patient leaves our office
4. We are losing family physicians to other parts of health care
5. It’s not an easy problem to resolve, but the longer we wait, the worse it gets
6. Investment in primary care needs to include investments in family doctors
You sit in the room, anxiously waiting for your doctor to arrive. In they come, and depending on how busy the day has been, they provide a brief greeting and are keen to hear what brings you to the office today. You provide a brief summary, and then begins the easy-paced rapid-fire series of questions you only hope you are answering ‘correctly’!
For many this process is a bit scary and mysterious. Wouldn’t it be nice to know what they are going to ask ahead of time? It’s like knowing what the questions will be on an upcoming test! Let’s learn how to mind read your doctor, and to rapidly give the key information needed so that they can accomplish a key objective for you – to make a diagnosis.
It’s incredible how often I have patients come in, and start the visit by telling me ‘I need you to look at my (insert body part here)’, such as ‘back’. I get it – something is wrong, and by telling me to look at it, they are in a way, respecting my ability to figure out what the problem is with my pre-x-ray vision (installed on all medical students early in the second year). What may surprise many of you, is how important it is to take what doctors call the ‘history’ beforehand. And I don’t mean just your past medical history (problems you have previously had, surgeries etc.), but your history of present illness (HPI – doctors don’t have time for anything, including talking, so everything has an acronym). This is the specific story about the symptoms you are currently coming in to discuss.
So how important is this part? Did you know that at least 70% of the time, doctors know the diagnosis just by asking questions!!! Think about that. Seven out of the last ten times you saw your doctor, they probably knew your diagnosis, before they even got up from their chair to examine you. Often, the physical exam (and even many of the tests we do), are actually done to prove our initial suspicions based on the history, or to rule out other conditions that we wouldn’t want to miss. The information you give them when you are answering questions is THE most important part of the visit. When someone starts a visit by asking me to look at some part of their body, what they don’t realize they have done is ask me to skip the part where I usually figure the problem out. Naturally, I routinely respond by asking them if I can ask a few questions first, because that is the most likely way for me to make that diagnosis.
So how do docs use questions to do that? What are these magic questions? There is actually logic to it all! The details are generally divided into 2 parts really. The first part is a set of questions, which doctors want to know for virtually every symptom there is. This is the nitty gritty background. This includes:
#1 Name the symptom:
#6 Aggravating/Alleviating Factors:
#7 What other symptoms do you have with it? (Promised you!)
#8 What treatments have you tried?
All the above applies to virtually every symptom there is – headache, nausea, any pain anywhere, numbness, dizziness, etc. Even anxiety and depression. Just about the only symptom where this breaks down a bit is a mole. That’s about it. If you have any other symptom, you should be able to answer a lot of, if not all the above. And the ‘stranger’ the symptom (think ‘brain fog’), the more essential it is to get all the above details to figure it out. You really want to think in detail about all this ahead of time, rather than struggling to remember the details during the visit, which will just take away valuable time that could be used for physical examination, testing, and treatment planning.
So is that it? No not quite. The above is important for every symptom, but after this there are usually a set of symptom specific questions, that it is not realistic to give you advice about in advance. For example, if a patient with a cough might be asked about recent travel, whereas for dizziness, or a mole that is likely irrelevant. But the reality is that I find it is the above questions that patients can have trouble with. What are the some of the challenges with all this?!
Challenge #1: Getting the right amount of detail
This one can be tricky to give advice about. If your doctor asks you how long ago your symptom you might say, “3 months ago”, or you might struggle to remember the date and tell them it was “around Easter”, or perhaps “a bit after the end of my trip in March”. These are all reasonable, but “3 months ago” is the easiest and most useful for your doctor. See, when doctors make diagnoses they either use algorithms, or use patterns of symptoms. Generally the doctor needs a number, followed by a unit of time (ex – 3 months, or 5 days, or 7 hours). If you are not sure feel free to give a range (for this, or any question), ideally with your best guess. Ex – “It was between 4 and 6 months ago, probably closer to 4”. It is generally better to start with a broader answer, and then add detail as you go. Watch for cues from your doctor. If they are quiet, they are probably getting useful information from you. If they are asking you questions, they probably need something else.
Challenge # 2: Getting the question answered before moving on
Sometimes patients just don’t realize that the question is actually helping me make the diagnosis. Doctors are very focused, and generally only ask key questions that lead them to the diagnosis. If the doctor asked you something, it really really matters! Do your best to answer the question they asked, and not a different one. For instance if your doctor asks how long ago the symptom started, try not to switch that to what time of day it bothers you. Both pieces of information may be important, but it’s easier to miss something when a question gets changed around.
Challenge #3: Changing subjects
In todays hectic world patients often come in and have a variety of unrelated concerns. Totally understandable! Dealing with everything in one visit seems efficient, and from your point of view will prevent a need for a repeat visit, which can mean taking more time off work, dealing with traffic again etc. This is unfortunately often due to payment models that do not adequately compensate physicians for taking the time to address multiple issues. One wants to be cautious though about distracting the doctor’s thought process at a key moment. If a line of questions has begun, and there is a pause, I recommend extreme caution about jumping in with ‘by the way I also have this form I need done’, or any other switch in subject. Your doctor was likely concentrating on your primary concern, and thinking hard about what they need to do next. Doctors have to bring overwhelming amounts of information into almost every decision they make. Think about trying to solve an algebra equation while someone is talking to you. It’s hard, if not impossible, to attend to both. You don’t want to break their train of thought, when those thoughts are about how to best protect your health. If the main concern that day hasn’t been completely dealt with, it might be best to ask the doctor if you can bring something else up before doing so.
Please remember that while all this advice is meant to help you engage with your physician, practice styles can be very different. Always work with your doc to build a collaborative relationship – it’s all about teamwork.
Preparing for a visit with your physician is a critical step that many people do not take enough time for. I can’t emphasize enough how important this is. I am a practicing physician myself, and could certainly ‘wing it’ through any visit I have with my own doctor, and yet I am careful to prepare every single time. The time available in the doctor’s office is often very limited, and doctors are under ever more pressure to work as fast as they can. Doctors often have to make complex decision fast. Like really, really fast. (I will make a future post on the number of medical decisions that go into a very simple medication refill another day). But we need to have complete and clear information to make those decisions. It is essential to use your time in the office efficiently, to get the most out of it. Your physician is likely
very skilled at gathering the information they need, but there are some simple steps you can take to make it easy for them. You naturally would prepare to go on vacation to enjoy your limited time away, & you should apply the same principle here. You want the visit to work well for you, and being prepared will make this more likely.
There are several steps to take in advance of the visit that are very helpful, and will give your doctor more complete insight into how you are doing, and what needs to be done.
First, it is essential to understand the general reason you are going in. Most people will think about a specific symptom (cough, headache, etc). But there is probably more to it than just that. Broadly speaking, I tend to think of patients who are coming in to see me as dealing with one of six ‘situations’. These include:
There are always exceptions, but the list above likely accounts for > 95% of patient encounters. The first step is to recognize which applies to you, and to recognize that for ANY one of the above situations, your physician will want to have enough time to do a complete assessment (I will be discussing more about what a 'complete assessment' means, and how much can realistically be covered during a single visit in a future posting too).
But there is more to it too, and this is really key!!! Whichever one of the above situations applies to you, there is also YOUR specific worry or problem with it. While there may not be a major one, more often than not, there is something that led you to be concerned about your situation.
Perhaps you are having a cough, and a friend of yours recently passed away when they had a similar cough. Now you are worried your cough might be something serious, like cancer. Perhaps a friend of yours had back pain, and was sent for an x-ray. Now you have back pain and you imagine, well, you must need an x-ray too. Or, perhaps a symptom you had is improving but you are still limited in some important way (ex - your fever is gone, but you are still coughing and can’t possibly give a speech at an upcoming conference). Perhaps you had testing done for a condition, and heard that the test is often done for people with cancer. Now you are wondering if your doctor suspects you have cancer.
All the above can be thought of as your feelings, ideas, functions, and expectations. The concepts for this were actually developed years ago at the University of Western Ontario and organized into an acronym taught in medical schools, and used by physicians called FIFE, which stands for:
F - Feelings – your worries about your illness
I - Ideas – what you think is causing your situation
F - Functioning - how your illness is affecting you
E - Expectations – what do you assume must be done
Many patients will naturally bring this information up, but physicians will also often spend time in the visit, trying to dig this out, as addressing it tends to lead to more satisfactory visits for both parties.
It is essential to understand that you can receive absolutely excellent medical advice, but still leave your visit feeling disappointed, or stressed, if any of these are not addressed!
Imagine for instance, that you go in to your appointment telling your doctor you came in because you have a cough. They gather some information about other symptoms, such as sore throat, runny nose, lack of fever. They examine you, and see no sign of serious infection. They correctly diagnose you with a viral illness, and correctly let you know you don’t need an x-ray or antibiotics, and that this will go away on its own over the coming days. The visit is then concluded. You leave, perhaps upset, because you are thinking about that speech you have to give. You
might not have even been that worried about the infection itself, and what you really needed was a cough suppressant so you could get through your talk. Your doctor managed your viral illness itself correctly, but the reason for your visit was never truly addressed. This example is meant to underline how important it is, for EACH condition that you are going to see your doctor for, that you consider ALL the above (FIFE), and then communicate this clearly to your doctor. The patient in the example above would have been well served by making their opening statement that they ‘have an annoying cough, which I am not that worried about, except that I have to give a speech tomorrow, and I really need to make the cough stop long enough to be able to give that speech’. The doctor is far more likely to not only assess the seriousness of the cough, and make their diagnosis, but also address managing the patient's primary concern as well.
Doctors are great at getting this information out, but its better still if you just tell them outright. Doctor's have many skills, and are taught how to read body language, but no one can read your mind. A good doctor will want to know all this, and it actually makes the visit go MUCH more smoothly once it's out in the open.
The most important part of a doctor’s work is gathering information. It's in your interest to know what you need to get out of your visit, and give your doctor that key piece of information right from the start!
We live in a rapid paced world, and nowhere is this pace both as fast (often after some serious waiting) as at the doctors office. Long and sometimes anxious waits in the office before your scheduled appointment, are then often followed by what can sometimes feel like a rushed visit with your doctor. Patients sometimes leave the office with unanswered questions, or lingering concerns about their condition.
You want to be listened to, and you want to know your doctor will act in your best interests. The good news is, this is in reality what your doctor wants too! The trick can be getting everyone on the same page, and allowing this to happen in the (brief) time available.
It has been said that often, the view from the other side of the fence is quite different. However, having this view can help you get over that fence. Our objective is to give you that view, and help you connect with your physician in the blog posts that follow we will try to give you valuable insight into how things work at the doctor’s office, how to properly prepare for your visit, how your doctor thinks and processes the information you provide, how best to communicate with them so they get the information you need them to have, and how to avoid some pitfalls.
While we cannot account for every circumstance, and there can be big differences from doctor to doctor, most of the insights we provide should be broadly applicable. We welcome comments, and will do our best to address them either directly, or in future posts.
North Shore Medical Group
We will be writing on a wide range of topics such as “How to Make the Most of Your Visit”, “When Does My Cold/Sore Throat Really Need Antibiotics”, and more…