Anne was one of the most difficult patients I encountered during my recent family medicine clerkship. My preceptor warned me before I went in to see her: “She’s … challenging. She’s a worrier. Brace for a lot of anxiety there.”
Within the first five minutes, I recognized that Anne most likely had a tension headache — something over half of all people will experience in their lives. Clinicians typically reassure patients afflicted with tension headaches of the headaches’ benign nature, encourage the patients to take ibuprofen and seek methods of relaxation, and then send the patients on their way.
This headache was Anne’s chief complaint.
The chief complaint answers the question "What brings you in?" It is usually described in terms of a symptom, such as difficulty breathing or chest pain, and is based on the patient's own perception. As the foundation of the clinician's biological and pathophysiological view of the patient, the chief complaint is essential for generating a differential diagnosis.
In Anne’s case the chief complaint and diagnosis were patently obvious. But since my next patient wasn’t scheduled to arrive for another 40 minutes, I decided to dig a little deeper. We could get back to Advil and self-care later.
Asking Anne about her daily stressors led to an outpouring about her difficulties with her husband, her four children, her mother who was recently hospitalized for a cardiac catheterization, and her new job at an elementary school. Once in a while she would pause a little, seeming uncertain about whether she was wasting my time. Partly because we had plenty of time, and admittedly partly because I didn’t quite know how else to respond, I would simply follow with, “Tell me more about that.”
Eventually, we circled back to her recurring headaches. I asked her what was different this time — what was it about her particular symptoms that led her to seek care today?
“I’m scared I have a brain aneurysm.”
I was taken aback. An aneurysm was at the very bottom of my differential. I briefly wondered what bogus online “medical advice” she might have come across.
I probed a little more and found out that two of Anne’s friends had recently passed away from ruptured intracranial aneurysms.
After making sure she had no risk factors for aneurysms, I responded, “Anne, I understand how scary it must be to worry that you have an aneurysm. But I can assure you that based on all the information you have given me, an aneurysm is one of the least likely causes of your headaches right now.”
She nodded, but I saw a lingering uncertainty.
“What distresses you most about this?” I asked.
“I’m scared about dying and leaving my children to my husband.”
And there it was. We had uncovered the chief concern.
The chief concern answers the question “So what?” It’s about meaning — “Why is this important to you?” ''What is it about this symptom that most worries you?" It is a piece in the narrative tapestry of a patient’s life, connected to their sense of how their life has been disrupted; who they are; and their day-to-day commitments, relationships, and values.
If the chief complaint is “back pain, can’t stand up properly,” the chief concern may be as simple as “the pain is too much to bear.” But it could also be “Can I still go on the cruise in three weeks, the one we’ve been planning for two years for our 50th wedding anniversary?” Or it may be “This is the same thing that happened to Aunt Margaret when she found out she had bone cancer and I worry it will happen to me too.”
I gave Anne some time to voice her frustrations about her husband, before mentioning that while her headaches weren’t anything dangerous, she needed to find a way to cope with her anxieties. Here, she interjected that she hadn’t spent time with a doctor like this since she last saw a therapist five years ago. I suggested she get back in touch with the therapist.
Noticing a tattoo of a crucifix on her forearm, I then asked, “Is spirituality something important to you?”
She tentatively nodded. “Church is pretty much the only thing keeping me sane.” Then she asked, hesitantly, “Do you go to church?”
“No, but it’s important to many of my patients, so I like to know about it,” I said. I was pleased by how much this disclosure seemed to improve our rapport. I listened as Anne discussed her favorite church activities, and I encouraged her to continue partaking in them. Toward the end of our visit, Anne mentioned that she had never brought up her faith with a doctor before, but how, after our conversation, she now identified it as an integral part of her well-being and health.
Even though the clinic visit ended without any medical prescriptions or referrals, I could tell the visit was fruitful for Anne. The entire visit had lasted only 30 minutes, but by the end, Anne admitted she had divulged more information — deeper information — than she had during any other previous doctor visit. And because those insights about herself came from herself, she identified meaningful interventions that only she could have known. While physicians are experts on guidelines for disease management, patients offer an often-untapped wealth of information about what will be most distinctively helpful to them.
Identifying and responding to the patient's chief concern reflects the physician's commitment to treating both a disease and the patient who has it, allowing us to connect with our patients at the most fundamental level. Compassionate care happens when we clinicians address what matters for our patients as defined by our patients. This is a key value for the empathetic clinician — “What matters for you is what matters for me.”
Moving forward, I now strive to augment my patient encounters by eliciting the chief concern, for I’ve seen that helping a patient recognize it is the best way to empower them to start playing an active role in their own care. And that is ultimately just about the most effective approach to health care there is.
How do you elicit patients' chief concerns? Share your strategies and experiences in the comments below.
Henry Bair is an MD/MBA candidate and Knight-Hennessy Scholar at Stanford University, where he also teaches courses on health care leadership, narrative medicine, and patient communication strategies. He is also a researcher at Stanford’s Center for Policy, Outcomes, and Prevention and fellow at Stanford’s Clinical Excellence Research Center.
All names and identifying information have been modified to protect patient privacy.
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