Every Patient Tells a Story Read Online Free PDF Page B

researchers, doctors, and patients would agree that time pressures play an important role. A visit to a doctor’s office lasts an average of twenty-two minutes. Although there is a sense that doctors are spending less time with their patients, that number has actually increased over the past twenty years. In 1989, the average doctor’s appointment lasted only sixteen minutes. Despite this extra time, both doctors and patients frequently agree that their time together is still too short.
    In response, doctors often depend on a few highly focused questions to extract the information they think will help them make a diagnosis quickly. Yet it is clear that this effort to reduce the time it takes to get a good history increases the risk of miscommunication and missed information. Like so many shortcuts, this information shortcut often ends up taking more time than those interviews in which patients are able to tell their stories in their own ways.
    Studies suggest that getting a good history allows doctors to order fewer tests and make fewer referrals—without taking any more time. Indeed, some studies suggest that obtaining a good history can even reduce visit time. In addition, patient satisfaction is higher, adherence to therapy is higher, symptom resolution is faster, lawsuits are less frequent.
    Lack of training may also contribute to the problem. Doctors spend two years in classrooms learning how to identify and categorize disease processes, matching symptoms to known disease entities, but until recently very fewprograms offered any training on how to obtain that essential information. The assumption seemed to be that this did not need to be taught. And there may have been an unspoken expectation that our improved diagnostic technology would reduce our dependence on this kind of personal information. Studies have shown that neither assumption is true, and now most medical schools offer classes in doctor-patient communication. Moreover, since 2004, medical students are required to demonstrate proficiency in their history-taking skills in order to become licensed physicians. A new generation of physicians may not use these tools, but at least they have them.
    Finally, many doctors are uncomfortable with the emotions that are sometimes associated with illness. When patients present their stories, they often look for cues from the doctor as to what type of information they should give. The interrogation format tells the patient that what’s needed from them are the facts and only the facts. And yet illness is often much more than a series of symptoms. The experience of being sick is frequently interlaced with feelings and meanings that shape and color a patient’s experience and perception of a disease in ways that are unimaginable, and unanticipated, by the doctor. A family history of heart disease or cancer may lead a patient to minimize a symptom. I recently got a phone call from a friend, a man in his late fifties whose father had heart disease. My friend was having chest pains when he walked up a hill. He wondered if this was his childhood asthma returning. He was shocked when I suggested he see a cardiologist. He had two blocked arteries, which were opened with complete resolution of his pain. The same history might cause another to focus on a symptom well beyond its actual severity. I have a few patients who have had many stress tests because of their concerns over their chest pain. The fact that previous tests have not shown heart disease provides them with no comfort or reassurance. Financial concerns may likewise affect how patients tell their stories.
    Worries about the social meaning of symptoms can complicate even a straightforward diagnosis. I learned this the hard way. A patient I saw when I was a resident came for a school physical. She was young and healthy. As I was finishing up and preparing to move on to the next patient, she suddenlyasked me about a lesion on her buttocks. Could it be from doing sit-ups