Chris Sumberg
Clinton, Tennessee, United States

In Life on the Mississippi, Mark Twain chronicled his difficult apprenticeship as a steamboat captain, relating his transition from simple observer who admires the beauty of the Mississippi River to designated protector of passengers and property, one who views eddies of water not as beautiful things in themselves but as markers of hidden shoals.

To some degree, any person with a vocation perceives the world through their specific vocational lens. The writer sees the beauty of the river; the ship captain anticipates the dangers there. Certainly, the vocational perspective (along with the usual distortion of subjectivity) is in play when physicians and their patients converse.

Consider that “How are you feeling?”, the first consultation question, seems straightforward enough. Here’s the problem though: if a non-doctor asks me that question, I will, as a tediously stoical man, answer “Dandy!”—even if my arm is broken. (The literal “least said, soonest mended” school of medicine.) But if a doctor asks the question, I (as a patient) probably will internally review a list of complaints that I might mention, even beyond the broken arm. In other words, right out of the gate, I’m expected to communicate with a physician as I communicate nowhere else—which is to say, efficiently (prioritizing my complaints), in detail, and with complete candor. Things that for months (even years) have been quietly worrying me beneath the veneer of public stoicism are now in play. Maybe I haven’t been sleeping, or am worried about a mole, or have an inexplicable pain in my ankle, or . . . whatever. The point is, and especially if visits to the doctor are infrequent, at what logical, commonly understood starting point do we two participants begin the unfamiliar but forthright and targeted conversation?

As patients, we understand that doctors have only so much time to consult with us. Additionally, doctors must work through a protocol of questions and examination screens—perhaps asking about our sleep, looking for moles, and asking about aches and pains. The patient, on the other hand, does not have an examination protocol. Patients, in what are often long run-ups to annual exams, fall back on a stew of their own observations, internet articles, half-trusted, non-physician opinions (yes, this was largely covered with “internet articles”), wishful thinking, anxiety, and who knows what else in forming lists of unprioritized, often redundant questions. The doctor, unfortunately, sees too many patients every day to form a truly accurate picture of any person. Sure, a physician might quickly identify very broadly a hypochondriac or a wishful thinker, but how can anyone parse the general observation into something more specific and useful in just a few minutes’ time? The doctor, having an examination protocol, might also assume at some subconscious level that the patient does too; that the patient will be intelligent enough to mention the most important thing on their mind first. But what if the patient is uncomfortable mentioning that potential issue—or thinks that it is “whiny” to mention small amounts of pain or that it is hypochondriacal to mention fears? Or, on the opposite end of the spectrum, what if the patient worries that the unspoken subject is, in fact, a very serious issue, one that would require testing, additional expense, and worry? An issue, then, that they would prefer not to address at all. What if the patient is chatty, or has tendency to control the conversation, or is nearly mute? Is the chatty patient anxious? Hyperactive? Mad? Is the dominant talker producing too much testosterone? (Check that prostate!) Has the mute had a mini-stroke? How can a doctor determine what is important if the patient, as a non-physican, cannot reasonably be expected to identify the key points—or to fully appreciate the effect that their own behavior or their disorganized mention of ailments might produce? A patient might say that their foot feels sore and they are experiencing pain when they walk. The amount of time it takes to determine where this pain is and how it might be defined —dull, sharp, arch, ankle, toes, not when resting, when running but not when walking, etc.—could take most of a consultation. What if the patient really is worried about something potentially more serious—or an “issue” that could be easily dismissed? The pain in the foot problem is a run-up to the real issue but whoops we’re out of time!

In fact, no surprise here, patients want doctors to operate as benevolent mind readers, to say, “Well, heya, Larry! Gee, has it already been six and a half years since I saw you last? Okay, upsy-daisy. (Is the examination table comfortable enough? Would you like a pillow?) Okay, I note from the the slight flushing and halo of sweat shimmering off your very being that you’re anxious. Let’s cut to the chase, Lare: You DON’T have cancer. And you never will. Here, take this free lollipop. Give my best to Loretta and the kids . . . Oh, and here’s a biscuit for Fluffy. Hope he’s over that ear mite issue. See you in 2023!”

Not that the above scenario couldn’t occur—and perhaps is occurring right now at a Dr. Nick-type clinic somewhere in the world—but in reality, anything approaching even reasonable doctor-patient communication requires a new standardized pre-examination process. Why not a simple pre-examination questionnaire? Something very compartmented would do the trick, perhaps web-based or available to waiting room patients through in-office tablets or kiosks. Better, as so many people now use smartphones and tablets, employing their own devices and a wireless connection in the office. Rest assured, documentation-weary physicians and patients, the form would feature no essay questions—and no doctor input! Instead, patients’ free-form, stream-of-consciousness examination monologues would be streamlined. Data fields would allow patients to prioritize their issues and their various symptoms (or from a doctor’s perspective, perhaps, non-issues and non-symptoms), even their sources of information or misinformation. Along with organizational benefits, a questionnaire would also apply useful distance to the self-revelatory requirements of a doctor’s exam. (Journalist Ted Koppel once noted that he preferred to interview subjects through a studio monitor because the impersonal nature of the video-only interaction allowed him to ask more direct questions than he might have in face-to-face encounters.)

The use of a questionnaire would not replace the give-and-take conversation of a doctor-patient consultation, but it would allow physicians and patients to target those conversations from the start and to derive the most benefit from them. In short, it would both compress and improve the entire “How are you feeling?” rigamarole, transforming it into something more like, “Glad we talked. Glad I could help.”