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When the Chief Complaint Isn't The Main Concern

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Recently I had the opportunity to provide feedback to one of my colleagues after an interview with a standardized patient. The scenario was an acute adult patient visit, in which the patient had viral symptoms but wanted an antibiotic—an all too common occurrence in primary care practice. She elicited the chief complaint, and then quickly launched into a focused review of systems. There was some tension trying to come up with a responsible plan that also quelled the patient’s misguided insistence on an antibiotic, but my colleague did a nice job of negotiating a two-day virtual visit follow up to see how things were progressing on supportive treatment.

I had many compliments for her, and only one suggestion.

“I wonder if it would help to be a bit more open-ended at the start of the visit,” I said. She was quick to latch on to the viral symptoms, astutely refining the history, but didn’t ask if there was anything else concerning this patient.

“But it was a sick visit, right?” she replied.

“Apparently so, but that is easy to talk about, and an emotionally safe reason to make an appointment.”

“I see where you’re going but, realistically, I would get so far behind schedule if I allowed every patient to turn a sick visit into a comprehensive evaluation,” she said, revealing the stress we all feel trying to get through our busy schedules efficiently.

“I get that,” I said, then went on to suggest that not every problem mentioned would need to be addressed that day, and at least we would know about them. I have also learned that there may be something else worse than the chief complaint, and offered to share an illuminating story.

My patient Joanna*, a young college student, came in with cough and congestion, which persisted unchanged for a week despite the usual over-the-counter remedies. Like my colleague, I swiftly moved into a pertinent systems review, then a physical exam. As I finished auscultating her lungs, I asked, “So how is life treating you otherwise?”

She poured forth a torrent of tears.

Joanna was struggling with anxiety, which had progressed to the point at which she was afraid to sit in small classrooms, fearing she may have to leave abruptly if panic symptoms took hold. Her grades dropped, she had withdrawn from friends and had even begun to have some suicidal thoughts. We came up with a treatment plan for her respiratory symptoms, started an SSRI and referred her for counseling.

I was a bit shaken when I left the exam room, imagining what might have happened to Joanna. I may have had the distinction of nailing the viral bronchitis diagnosis, and missing an opportunity to prevent a suicide. This has drastically changed how I view the chief complaint.

I have come to appreciate that the chief complaint may be a way in the door, something the patient is comfortable discussing, and what she perceives will be a doctor’s priority. Patients may be ashamed of their deepest concerns, or afraid of the possible diagnosis. As a physician, I can relate to the fear of losing control of the visit, uncovering an issue that is time consuming and may delay my schedule.

I wonder if it is time to do away with the “chief complaint” and replace it with “initial complaint,” and then a new category, “main concern.” This would be a nice prompt to help make sure I know the full extent of why the patient is seeking my care. Getting to the underlying concern is challenging for physician and patient, because it taps into our vulnerability. Joanna reminded me of the risk of allowing the chief complaint to inform why the patient is in my office, and that I must face my fears of what open-ended interviewing may bring. Such an invitation, through words or gestures, may be the key to unlocking my patient’s truest concerns. Oh, and yes, it may be lifesaving too.

*All names and identifying information have been modified to protect patient privacy

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