The chief complaint, now often referred to by providers as the “presenting concern,” is the center on which most medical encounters will focus. It’s the answer to that most essential question: “What brings you in today?”
Most of us spout off a list of symptoms in no particular order, scattered across a vague timeline. This might be because it’s nerve-racking to be put on the spot, or because the problem is a blur we haven’t had time to work through in our minds.
It’s helpful to create a narrative or story around the situation prior to going to the appointment. This will give your symptoms context and provide meaning to the timeline, and you’ll naturally equip your provider with key information you may not even realize is relevant.
Take a few notes in the comfort of your own home before you get on unfamiliar turf. The evening before your appointment, so it’s fresh in your mind, write down the main bullet points for what you’re going to share with your provider when they give you the floor. You might even want to practice the little talk on someone you know, ideally your advocate (see “Choosing an Advocate”).
It may sound like I’m setting you up for a stiff, choreographed interaction, but the appointment should be anything but! Think of this preparation as scaffolding for a conversation. It will spare you the heartache and frustration of a wasted appointment that you leave wondering what, exactly, was accomplished.
Creating an Elevator Complaint
The art of the “elevator complaint”—a short, eloquent story about what ails you—requires you to be detailed but not exhaustive, both thorough and concise. Trim down your notes about your symptoms to the most essential. Watch out for things that may invite a long digression into your history, and parse out extraneous topics that relate only insofar as they have to do with your body and you’re on an exam bench. Do you need a flu shot? Want to know when you’re due for your next pelvic exam? Want to change a medication to a generic version? Save these sundry points to cover at the end of the appointment. It might seem reasonable to list off every ache and pain you’ve experienced from the cradle to your 9 a.m. appointment while you’ve got your provider’s attention, but don’t make elephants out of flies. Listing multiple complaints creates noise, and diagnosis is about limiting the noise. It’s also liable to send you on a wild-goose chase through the medical system. The elevator complaint is the place to execute focus.
Try to pare your list of complaints down to two to four symptoms that are most pressing, or are impacting the quality of your days most intensely.
For each symptom, include the following information:
Onset (when did it start?)
Frequency
What aggravates it
Typical duration
What alleviates it
Any remedies you’ve tried that didn’t work
If you’re feeling stuck, try some of the following phrases (also see here for help describing pain):
(days/weeks/months) ago I started experiencing .
This symptom (is unremitting/comes and goes/lasts for weeks at a time/is unbearable for thirty minutes, then resolves/is the same severity every time/fluctuates in severity).
This was (followed by/accompanied by) .
The symptom is (like when you get motion sickness/sudden and shooting like a pinched nerve), not (like an upset stomach before you throw up/dull like a stomachache).
The symptom (is worse/seems to flare up) when .
I’ve tried (over-the-counter medications/an elimination diet/physical therapy) to relieve the symptom.
This has affected my ability to (work/exercise/get out of bed/be outdoors/concentrate for long periods of time).
Put together a timeline. Think about the onset of the problem(s) at hand. Which symptom(s) began first? Did they all begin simultaneously? Has one been a chronic problem for years that recently changed in frequency and/or intensity? Does one symptom exacerbate another?
Then consider anything from your medical history that might be relevant. If you have a compilation of your records (see here), flag anything that might be connected. Even if your provider already has access to this information, it’s helpful to draw their attention to anything relevant up front so they don’t have to search.
Once you have assembled all this information, you can craft your opening statement. For example:
Two months ago, I started having nerve pain in my upper neck following strenuous activity. The pain tends to last for seven to eight hours once it starts. I’ve tried Advil, applying heat, and chiropractic sessions every month, but nothing makes a difference. Because of the pain, I’ve had difficulty sleeping for the last several weeks. I used to get eight hours a night, but I’m now getting closer to four. The neck pain also gives me migraines, which are a new symptom for me and debilitating. I’m missing work and family activities because light and noise exacerbate the migraines. I have a history of disc problems and chronic lower-back pain. I had X-rays one year ago that ruled out certain causes, but they didn’t come to any conclusions. The notes from this visit are here in my medical record.
Three years ago the National Academy of Medicine reported that people are likely to receive a late or incorrect diagnosis at least once in their lives. That’s twelve million people annually.1 To complicate the picture, there are several types of diagnostic failings. Understanding these concepts from the outset, while you’re receiving care, can help you guide discussions with your provider.
Among the different types of misdiagnosis are:
Misdiagnosis: The general term for the incorrect assessment and diagnosis of a disease.
Missed diagnosis: The failure to identify and diagnose a disease already underway.
Delayed diagnosis: Failure to identify, diagnose, and intervene at the onset of symptoms, resulting in delayed care and poorer prognosis once the disease is diagnosed.
Overdiagnosis: An accurate diagnosis and intent to intervene for a disease that will not cause problems in the patient’s lifetime, such as a slow-growing cancer in an eighty-year-old patient.
Underdiagnosis: A condition or disease that goes undiagnosed within a specific population or context—for example, heart attacks in women or unaccompanied by pain.
Confidence. It plays a critical role in how providers come to conclusions when they diagnose patients, and research now shows it’s the thing most likely to get us into trouble.
One of the tenets of medical education is using a form of deductive reasoning to come to decisions about what is going on with a patient—what disease or condition is expressing itself, and how to proceed. Deductive reasoning, also called top-down reasoning, can take the form of decision-making trees. Imagine a hospital room where a medical student is being interrogated by the attending doctor at a bedside:
Attending: Please present on Mrs. Fisher.
Student: Mrs. Fisher is a forty-five-year-old female with lobular carcinoma in situ, admitted on 8/1 due to postsurgical complications. She has a progressive, two-day history of neutropenia and is intermittently febrile at 38.3°C. Source of infection remains unclear.
Attending: What’s your assessment?
What follows is a path down an algorithm tree that’s been freshly etched into the medical student’s brain. They’ll come up with differentials, or, possible diagnoses based on symptoms, and either rule them out or hone in on them based on the case at hand.
Student: Based on A and B, we’ve ruled out C, D, and E. Because of F, it’s likely to be in category G, so the possibilities are X and Y.
These decision-making trees are the scaffolding for making a diagnosis and executing a plan. Providers use them to create an accurate picture of their patient’s symptoms and implement treatments accordingly.
But these trees can be inflexible. The provider often reproduces them for each patient displaying the same set of symptoms, and uses their pathways over and over again through experience. This model usually works, but it also has the tendency to place more emphasis on ticking off boxes than on thinking outside them, leading to diagnostic misses.
It can add up to a restrictive thought process that puts a provider on a path straight to I’m so right, I’m wrong, a path we’ve all traversed at some point or another.
In order to understand the neural underpinnings of this medical tendency toward premature certainty, researchers at the University of São Paulo Medical School in Brazil used functional magnetic resonance imaging (MRIs) to examine how doctors’ brains work as they make diagnoses.
In the study, primary care providers were shown a set of symptoms and asked to identify the disease they indicated. For example, a productive cough, sore throat, inflammation of the bronchioles, and chest tightness were linked to bronchitis. Interspersed throughout these identifications, the physicians were shown words and phrases and asked to name the animal they indicated—for example, the words “meow,” “domestic animal,” and “black fur” suggested a cat.
The researchers demonstrated that the areas of the brain that lit up during these processes were the same—naming a cat and using symptoms to diagnose a disease required the same cognitive pathways.
Next, the MRIs showed that when the physicians had to think about less-specific diagnostic information that could be associated with any number of diseases (nasal congestion, for instance), activity increased in the brain system known as the frontoparietal attention network—that is, their attention intensified. But the physician’s attention was reduced if they were given highly specific information, strongly associated with a particular disease, at the start. This suggests that as a provider becomes more certain of a diagnosis, their attention to the matter decreases.
In other cases, symptoms or conditions that result from a different problem are dismissed or looped into the primary diagnosis. This was also shown in the São Paulo study: Physicians associated low thyroxine with hypothyroidism (which makes sense), but this interrupted any investigation of depression—which can appear with hypothyroidism and requires a separate course of action. If you’re told an animal has whiskers, laps milk, purrs, and naps, you’re likely to think: house cat! But what if it’s one of those domesticated foxes?
Other studies have corroborated the São Paulo study. One showed that if, at the beginning of a medical encounter, providers are given a list of possible diagnoses that all merit equal consideration, they are more likely to make an accurate diagnosis. In essence, overcertainty and overconfidence early on in a clinical encounter increase the likelihood of premature diagnosis—a common source of medical error.
So what can you do about the possibility of diagnostic mistakes? Well, just knowing that it’s a phenomenon will change the way you approach a medical encounter. It’s a reminder that things are always a little more complicated than they seem, so don’t be afraid to push back or ask a provider to explain their reasoning if they rush straight to what they think is a bulletproof conclusion but you’re not convinced. You can also contribute ideas about what you think a problem might be, and doing so is likely to be more beneficial at the beginning of the encounter, and if you include more than one option.
Earlier, in “Should I Google My Symptoms?” in chapter 4, I outlined ways to use (and not use) the Internet as a tool to understand your symptoms and prepare to navigate the medical encounter. Later, in “Mastering Disease,” there’s more information about how to master this process, especially when you have a chronic illness. For now, though, just remember that providers’ brains work in patterns, and pushing them to think in less rigid, self-contained ways, while acknowledging and utilizing their expertise, can elevate the quality of care you receive.