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SPOTLIGHT
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Grudging answers, too many questions

Published on -4/15/2013, 10:09 AM

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Ruth Firestone is right -- doctors don't always know best -- but she uses poor examples to illustrate that truism.

In a recent column, she laments the imposition of "patronizing" questions such as "why are you visiting the doctor?"

What she considers a "drill," nurses term "intake" or even "triage." It typically starts with "purpose of visit" (POV) or "chief complaint" (CC). It's annoying when nurses ask her why she's come for medical care; shouldn't that be right there in the record? Sorry, it's just not prudent to assume that everything that needs to be in the record is in the record -- and 100 percent accurate, to boot.

Many patients initiate appointments on their own, or even appear as unscheduled "walk-ins," with new problems. Those won't be in the record. Some people are reluctant to share with the appointments clerk the fact that their hemorrhoids itch like crazy, so it's still not in any record.

It's not uncommon to see a patient whose visit has indeed been requested by the provider, but who doesn't really understand why. Their response to a routine "why are you here?" turns out to be "I don't know, the doctor wanted to see me." The fact that the patient doesn't understand what's going on has great practical significance for ultimate success, and reveals an additional problem that must be corrected. (Contrary to Firestone's misgivings, asking such questions is not the way we detect dementia!)

Even those with pre-scheduled visits might also want to discuss a new-onset problem, even though their primary purpose is a routine blood-pressure follow-up. How do we know if we don't ask?

How indeed? One might suppose that the patient would just volunteer such obviously important information, but as Firestone goes on to demonstrate in her own case, that doesn't always happen.

Asked to assess her level of pain with a simple numerical scale, she couldn't figure out how to do it. She's only a "five" at the moment, but much of the time she's a "10." Those are her only options, so she goes with the present "five," fearing it could be misleading, and result in under-appreciation of her overall level of distress. Instead of asking for a number, she proposes nurses "go through the descriptions of the ascending levels until the patient finds the best match." Given the enormous variety of pain syndromes, this is a truly absurd notion, but if such a list exists, I'd love to see it!

Fluctuating pain is a common problem. Here's what people usually say: "well, right now, it's only a five, but a lot of times it's a 10." Was that so hard?

What would be poor doctoring would be basing an entire pain evaluation and management strategy on a single numerical assessment during triage, as Firestone suggests happened to her. That's nowhere near the intent of triage pain inquiries.

Docs must subsequently expand that information -- where does it hurt, how long has pain been there, is it steady or intermittent, what makes it better or worse, etc. A critical issue is whether the pain compromises activities of daily living -- eating, work, sex, recreation or sleep. Such inquiries are guided by the patient's responses during triage. Nobody insists "you said 'five' in triage, and that's all we need."

Without detailed information, insightful pain management is impossible. Unfortunately, many docs are not trained or experienced in modern concepts of pain and its full spectrum of treatment. That's not due to over-reliance on pain screening in triage, however.

All pain is inherently subjective; subjective scales cannot serve to eliminate systematic evaluation, nor can they be replaced by a blood test to somehow quantify pain.

Not all pain causes suffering, and individuals vary greatly in their ability to tolerate pain. The same condition that creates a pain severity rated "two" for one person might create a "seven" for another.

Though individuals vary among themselves, we can usually assume that low pain ratings are less likely to represent a serious problem for any individual. When a given person's sequential pain ratings begin to trend downward, we can infer a beneficial response to treatment. When ratings trend upward over time, we can infer the treatment is inadequate, or the underlying disease process is changing.

A mid-range "five" should be considered serious, even though it could be worse.

Good medical care, and optimal outcomes, involve contributions from both patient and physician in a therapeutic alliance. That means both parties must ask questions. True enough, busy docs don't always do a good job of answering patient inquiries; but for patients to answer queries in triage or the exam room should not be so challenging as Firestone asserts -- especially something so simple as "I'm here because my (blank) hurts."

That "list" of triage questions to which Firestone referred enhances our ability to provide comprehensive care. In addition to the "vitals," we check on health maintenance issues -- is the patient up-to-date on Pap smears, mammography, glucose and lipid screening, immunizations, tobacco counseling? (Much of which is in the chart.)

For special populations such as diabetics, other screening is routine -- dental referrals, exercise counseling, kidney function check, extremity circulation, skin breakdown. These inquiries can usually be conducted in five minutes or less, excluding ordering and collecting blood and urine specimens.

The more information your medical providers can employ to guide your care, the better the care is likely to be. They can look, thump and harrumph, but unless you share what you know, you deprive them of a critical tool.

Jon Hauxwell, MD, is a retired family physician who grew up in Stockton and now lives outside Hays. hauxwell@ruraltel.net

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