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Asking questions
Mary G. Barry, MD
I
Louisville Medicine Editor
[email protected]
spend about 90 percent of my day asking
people things, while simultaneously typing the answers. What’s on your mind
to discuss? How are you doing? How are
things? What’s the matter? Are you sick?
When did you last feel well?
I ask my staff. Have you faxed it? Have
you called it in? Have you gotten a hold
of Dr. Sadlo? Have you called the Unit to
confirm that they actually got the fax? Have
you asked the pharmacist? Have you talked
to Ms. Old Lady’s daughter ‘cause remember
the patient is ah, useless? Have you sent it
back to me? Have you sent the referral out?
Have you gotten the PA form? Is the fever
lady coming now? Have you done the See
Todays? Have you changed my schedule?
Have you taken the x-ray thing over to Barbara? Has Ms. T come back from Dexa? Has
the lady in 8 peed in a cup? Have you taken
it downstairs yet? Has the man in 10 had his
minineb? Sharon, have you had any lunch?
Do you need a banana?
I ask the night nurses, since I round early.
Did he get any sleep? Did his heart rate
fall? Did he use his CPAP? Did his pain
medicine help? Is he still out to lunch? Did
his sats drop? Did he ever get out of bed
yesterday? Did his sugar behave? Did he
eat actual food? How much urine did he
make? Does he look better to you? Did you
all have a good night?
I ask the people who accompany patients
to the exam room. Does she snore? Do you
think she’s worse or better? Do you think
she eats enough? Do you think he’s taking
enough pain medicine? Is there anything
you’re worried about that he brought you
along to tell me?
I ask the person on the other end of the
phone. Have you taken your temperature?
Do you own a thermometer? Have you kept
anything down? How many times have you
gone? May I speak to the sick person please?
Are you coughing up anything? How long
was the tick on you?
But the most interesting questions come
in the midst of a sick person visit. You were
fine and then bam, out of the blue, your
belly hurt – what were you doing at that moment? Where in your belly? Did it stay just
there? Did it go anywhere? What did it feel
like? Sharp like a knife or sharp like intense?
Could you do anything to make it better?
Could you do anything to make it worse?
What happened if you walked? What happened if you turned over? What happened
if you drank something? What did you last
eat? How long ago? So you’re sort of nauseated but not throwing up? Have you eaten
leftovers or party food or restaurant food
or any food you think might have done this
to you? Have you lost your appetite? Have
you kept liquids down? Does it hurt to pee?
Does your urine look funny? Smell funny?
So the pain is right under your ribs in the
top of your belly, anybody in your family
had gallstones? Have you been pounding
down vodka by any chance? Has your stool
color changed? Do you feel weak and sick,
or just sick? Are you dizzy when you stand
up? Did you take any kind of pill for this?
Interrogation techniques are required.
Rudyard Kipling’s “Who What Where When
How and Why do you think you have this?”
must be pinned down quickly. Making
them start the story at the moment before
the symptoms began, tell all and yet not
lose track demands a quick ear and a firm
hand. The person who begins her tale with
“It could have been Thursday but maybe
it was Tuesday” probably is not going to
worry you much, but the person who says, “I
came around the corner of my house Friday
morning and dropped to my knees” has a
shot at having something wrong with them,
even if just a flair for the over-dramatic.
Rapid-fire questions keep the person on
track and make them focus on what they
have felt. Doctors get to be both the good
cop and bad cop in one visit (“Your eyes
look like you feel bad but not awful” we say
– good cop – right before we find that tender
costovertebral angle – ow! - bad cop). We
try never to lead the witness, therefore we
chip away relentlessly with yes/no questions
and keep demanding detail for which they
must choose the adjectives. Socratic questions are good, to demonstrate at what level
they understand the complaint. Rhetorical
questions waste time. Confirming questions
are the best fun. If I think you have A or B,
or less likely C, I ask “So it feels better when
you cough?” knowing that if they say no, it
will be A and furthermore, if they look at
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