Preparing For Your Visit – Part II: How to Mind-Read Your Doctor

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:

• This is of course by far the most important one, and surprisingly often challenging. It can be hard to describe in words what something feels like, especially when you don’t really know what’s causing it. Arm pain, leg pain, abdominal pain are all fairly straightforward, and simple for the doctor to approach. ‘Brain fog’…not so much (and unfortunately there is no medical textbook that doctors ever use that describes how to diagnose and manage ‘brain fog’). 
• It is VERY helpful, if you start by identifying a SINGLE main symptom to start with. This is NOT meant to restrict you, but rather makes it easier to move through the rest of the discussion. A good doctor will always ask about associated symptoms, so you can bring those up too. For example, you might start by mentioning your cough, saving your runny nose, sore throat, and fever for a short time later. For many doctors this will even be the very next question, but letting them focus on ‘cough’ for the first brief moment helps the doctor focus their attention and start immediately formulating an approach to the diagnosis.

#2 Timing:

• When did this symptom start?
• How long does it last when it occurs?

 
#3 Severity:

• How bad is it on a scale of 1-10? or if it is hard to rate that way, then:
• What does it interfere with / stop you from doing in your life?

 
#4 Course:

• Overall, is it getting better / worse over time?
• How rapidly?

 
#5 Location:

• As specifically as possible, where do you notice the symptom (ex – for abdominal pain, is it everywhere, or just part of the abdomen)?
• Does it radiate anywhere?

 
#6 Aggravating/Alleviating Factors:

• What makes it feel better / worse
• Ex – exercise, spicy food, coffee

 
#7 What other symptoms do you have with it? (Promised you!)

• Here you can go wild – you want to go ahead and mention anything that you think is, or even may, be related to your primary symptom. I will routinely hear my patient say ‘I don’t know if this is important but I also have (insert symptom here)’. Totally cool with that! I do think you should allow that your doctor might decide it’s not relevant and then save that up for another visit. If you remain worried at the end about that symptom, and feel like it was unaccounted for, make a separate visit where that one is now the primary symptom, so you can have that one fully evaluated too.

 
#8 What treatments have you tried?

• Each type of treatment you tried (medications, physiotherapy, other)
• How much you tried the treatment (ex – Tylenol was 3 times a day for 1 week vs sporadic; or physiotherapy 2x/week for 4 weeks)
• How much that treatment helped (a little, medium, or a lot is usually clear enough)
• Were there any problems with that treatment (ex – I felt nauseous with the advil I had; or the physiotherapy actually made things worse)

 
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.