I open the door and enter the exam room, with usually one or two seated strangers facing me. “How do you do? I’m Dr. Rensimer.”, shaking their hands. Immediately I sit, to be at eye-level, most often 4-6 feet away. With my sheet of paper down and pen in hand I start, “Tell me your story.”
That is an introduction crafted over 40 years of practicing medicine. I am telling them I am there to listen. They open in a variety of ways, sometimes detailing their present worry, or their suffering, or the diagnosis they have been given by previous doctors or their personal opinion. I let them briefly explain what is foremost on their minds. How they have been medically handled and managed before they found or were directed to me is critical. Finally, I need to understand what they have come or been brought to believe about their situation, which often culminates in anxiety, fear, depression, suffering, and misguided expectations and anger.
Once I take that all in, I ask them to start at the onset, the very beginning of the story that brought them here. I want the chronology, the timeline. I want the pace of events. I want what things were done, when they were done, and how long they were done and how those things affected or failed to affect the problem. I want them to detail levels of care (hospital or otherwise), other physicians involved (and what they told them and what they did), and any diagnostic studies or procedures that had been applied.
Note, none of this so far mentions any technical medical vernacular, such as diagnostic terms or labels. It is akin to a journalist constructing a narrative. In that, it draws on the most critical tool a physician has–listening. “Hearing” what the patient has to say. It is physician directed storytelling.
It is not the stethoscope, laboratory tests, or imaging studies. These days, it is not the laptop computer or tablet, either. It is the tool that has always been the key to successful diagnosis and the best medical decision-making. Listening, carefully, meticulously, then putting the facts to paper as dots or points in a somewhat random array, the lines between which will be ultimately connected by the vast and deep databases in an experienced and highly cultivated medical mind, with a sprinkling of what, at times, seems mystical intuition.
Patients (and many physicians) often prematurely rush to diagnostic labels (pneumonia, cellulitis, urinary tract infection, cancer) because of what they have been labeled by others, prior to seeing me, or by their own forays on the Internet about their problem. I stop them and tell them to leave the labels behind after I have documented them. We are going to dissemble pre-existing labels and premises and re-assemble their story, the colloquial narrative of their problem, from the most simple elements, the unlabeled minutia (without medical vernacular applied). It is essential to intellectually hang back from the tree-line and consider the forest (the big picture) instead of rushing into the trees (specific diagnosis) and getting lost in dead-ends. Be clear, we are talking about challenging problems or diagnoses, not pregnancy. A diagnosis, especially in cases of uncommon patient complaints, physical exam findings, unusual laboratory results, abnormal findings on imaging studies, or an atypical clinical course of illness should be assigned only after painstaking review and recording of the patient’s history, their story. Nuanced listening and purposeful questioning wins the day.
I attended the Temple University School of Medicine in the early 1970’s and so our instructors were “old-school” academic physicians, professors who trained in the 1940’s and 1950’s, long before technology provided the diagnostic tools we take as a given today (in fact, for the past 30-35 years: ultrasound studies, CT and MRI scans, molecular and nucleic acid testing, etc.). Those physicians had only the most basic blood tests and imaging tools (X-rays) to arrive at a diagnosis. I recall an esteemed professor, Thomas Durant, MD, well into his 70’s, teaching us that with a proper medical history from the patient (their story) you would have enough information upon leaving the room from the first encounter to correctly diagnose the problem over 95% of the time. Testing would only validate what you already knew. Of course, it is their story processed with an encyclopedic base of medical knowledge and skill in integrating cellular biology and physiology, pathology (the science of disease), organ function, metabolism and body chemistry, and numerous others supporting disciplines, such as macro- and microanatomy, microbiology, pharmacology, endocrinology, and overall wellness physiology, and others. This mix of medical knowledge and skill and understanding, applied to the patient’s story, leads to accurate conclusions and pathways for defining the biological nature, as well as severity and extent, of the patient’s problem.
This, in total, is the magic of the mind of a physician–the elemental reason I decided medicine would be my life at 16 yrs-old. I wanted to know how doctors think. How do you enter a room with another individual and with your eyes, ears, hands, and mind penetrate their body, through information gathering and analytical thought, and then reason what might be the problem and its solution? What do you look for? How? What questions do you ask? How do you then put it together? This is the ethereal, rarefied realm of the diagnostician. It is what I aspired to as a young student and where I directed myself for life. And, 45 years later, I have concluded, like my wise mentor professors of medicine, it is about the story. But, be clear, it all starts with the skill of listening. And, for other than the most mundane medical problem (such as a sprained ankle or an ingrown toenail), this process can only occur at the level of a licensed physician. No surrogate, such a Physician’s Assistant or Nurse Practitioner, can ever perform at this level. They simply lack the intensity and depth of training and education that starts with the most difficult basic science, pre-med courses in college (advanced general biology, cellular biology, chemistry, biochemistry, comparative anatomy, physics), and then 4 years of the most intense courses imaginable in medical school (too numerous to list entirely). But, the process of mastery was only completed (but continuous, ongoing) after I had been in practice about 5 years and thousands and thousands of difficult cases. However, every medical worker, at their respective level, can commit to learning to listen attentively and analytically, to perform optimally in their scope of practice.
Over the past 25 years or so, the cases on which I appear to be brilliant to colleagues and to those under my care are usually solved because of my unequivocal belief in what I was taught by revered physician educators- that our highest duty to a patient is to achieve an accurate diagnosis at lowest cost and least risk and then to obtain the best outcome possible by skilled management decision-making. Unequivocally, they told us, your greatest tool and skill is listening and then applying what you know medically to that story. Every complex story has nuances hidden by what is offered up front, residing between the lines of the story. Every week I have new cases that bring me to ask 3 or 4 questions beyond the first obvious one, because of my conviction in the critical necessity of painstaking method in medical history-taking… the story… to dig into what is deeper. The case solutions are there. But, to do this requires time and unrelenting focus. This is where the passion of medicine resides. And, patients report this is an uncommon experience.
For a variety of reasons- electronic health records with the doctor staring at a computer or tablet during your visit, use of Physician Assistants and Nurse Practitioner surrogates (for physicians), and increasingly marginal insurance fee payments for time, the profession has (I believe irresponsibly and disgracefully) abrogated the essence of what physicians must be– wholly attentive to and singularly focused on the individual presenting for their care. In our practice our greatest, seemingly unsolvable, problem is patient complaints about waiting to see me. Why? Because I refuse to practice medicine in any but the proper way. There is no substitute for the time with a focused physician. At least I hear, upon leaving, almost all the patients comment to my staff that I was worth the wait. They know they were given the time needed to be serious about their problem. A good thing for me, but an extremely sad and unseemly commentary on the profession- that the virtue of time given by the physician to the patient, to listening to them, is an uncommon virtue and experience.
More computers, newer drugs, more advanced testing methods- none of this will translate into medical excellence and optimal patient experience and outcomes so much as physicians deciding to push all that aside as subordinate to a pen, a piece of paper, and a quiet room, with an unrushed physician making eye contact with the patient, “Tell me your story.”
Edward R. Rensimer, MD