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.

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:

1. To discuss a new symptom
2. To review a symptom, (or chronic health condition) that was already discussed or is being treated
3. To discuss a test result
4. To refill medications
5. For a general health checkup or preventive care
6. To have forms / paperwork completed

 
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

• What are you most concerned about?
• Do you have any specific fears or worries right now? 

 I - Ideas – what you think is causing your situation

• What do you think might be going on?
• What do you think your symptom means (ex – your back pain means your back is ‘messed up’, or perhaps that you must not work because it will get injured more)?
• Do you have ideas about what might have caused this illness?

 
 F - Functioning  - how your illness is affecting you

• How has your illness affected you day to day?
• What have you had to give up because of your illness? (Social plans, work time, a trip)
• How has your illness affected your current goals?
• How does this illness affect important people in your life (ex – I am sick in bed, so my partner can’t work and must look after the kids)?

 
E - Expectations – what do you assume must be done

• What do you expect or hope the doctor can do for you today? (Need that cough to stop for my upcoming speech)
• Do you have expectations about how your doctor will help? (I have bronchitis, that must mean I need antibiotics)
• Do you imagine certain specific tests or treatments are needed? (‘My friend had an x-ray for their back pain, I must need one too’).
• What do you hope this treatment will do for you?
• What are your expectations about what might happen with this illness?

 
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!