I’m pretty sure that I know how to take a history from a patient, although I joke that it’s much easier to cut first and ask questions later. My questions are posed to dissect out the basis of the patient’s problem, taking the complaint and narrowing it down to the smallest differential possible.  Like Doctor House, I believe I’m a detective sorting through carefully hidden clues, then while asking the correct questions, I listen to the response given by the patient and then carefully formulate a plan to verify the diagnosis and subsequently initiate treatment.  Heck, I even look at their body language and their breathing pattern to guide me in the right direction.

I won’t tell you how long I’ve been doing this, but I guess long enough to know that the more I think I know, the more obvious to me it is that I don’t know much of anything in this universe of medicine and I often pray to God to help me in the difficult situations.  And yet, I’m confident enough in what I’m doing to know that the better I listen to the patient, the more likely it is that he or she will lay the answer right in front of me like a ridiculous steaming plate of lobster next to a cup of hot butter, accompanied by a crisp salad and a large pitcher of cold beer.

And without fail, patients are eager to answer my educated questions because they want help and they want a quick and accurate diagnosis, and if testing is needed prior to treatment, they want the best test possible to efficiently nail down the diagnosis.

But all of this came to a screeching halt when Ms. X walked into my office.

“Hi Ms. X, nice to meet you.  Have a seat.  What may I do for you today?”

“Hi. I have Central sleep apnea, not Obstructive, and I need a home sleep study, not an in lab study.  That’s why I’m here.”

Taken aback a little by a patient making her own diagnosis without my input, then essentially ordering her own tests, I scratched my chin a little and thought about what the right approach would be.  I figured I would use my finely honed interviewing skills to find out if she even needed any testing and that in fact, maybe, she had something different going on.  She looked nervous and her arms were folded in front of her perfectly.

“Ok, what is bothering you about your sleep?”

“What do you mean?  I have Central Sleep Apnea, I know it and I need a home sleep study because I know I won’t sleep in a lab.”

My patience was evaporating quickly, like the morning dew in Phoenix.  I felt my patience try to morph into indignance, but I told it not yet please.  Must have sangfroid.

“Do you snore?”

“Of course not. Why would I snore if I had Central Sleep Apnea?”

“Are you sleepy during the day?”

“You mean, do I have insomnia?  No, I don’t have insomnia.  I told you I needed a Home Sleep Study.”

Stubbornly, I refused to let her run the show and continued my now impatient attempt to get to the bottom of her real problem.  But I could feel my leg start to move like it was running the 100 meter dash under my desk.

“So when do you go to bed, and how long does it take to get to sleep?

“I told you, I don’t have insomnia.”

I amazed myself that I was able to continue without throwing her out of my office, an office that previously garnered a little respect from patients who sometimes paid me for my education and skill.  But then, I realized, if I threw her out, I would hear about it in the papers or from her money sucking lawyer.  So, I tried to get her to answer a couple more questions to narrow down the diagnosis that I already knew.

“What kind of work do you do?”

“What difference does it make?  Why do you ask that?”

I was taken aback by her question.  Why the hell wouldn’t I ask whatever I wanted, within reason, to get to the truth?  I stared at her, said nothing for a loud minute, and I felt my face start its’ journey to flush town.  I didn’t feel I needed to explain each question I asked, but thought I would give her a generous benefit on just this one explanation.

“Jobs make a difference, for example, time commitments, late hours, stress etc.”

“Not applicable here.”

Her arms, already folded in front of her emaciated, coffee – stimulated body now seemed to caress her chest with increased vigor, and I could see her fingers blanch from the pressure.  I decided I would save the last few precious moments of calmness I had by asking a quick double question to see if she responded.

“So, do you have a family history of sleep disorders, and how long have you been living at this altitude?”

“Why would you ask about my family history?  And why would you care how long I lived here?”

Both of my legs were jumping now, supported on the balls of my feet, but they were controlled enough so that I knew she wouldn’t see them or see my body vibrate, ready to explode.

“I ask these questions because I am trying to figure out how to help you, Ms. X. For example, if there is a family history of Sleep Apnea or Narcolepsy it is helpful in the evaluation, or, if you recently moved to altitude from sea level, it could play a role in Central Sleep Apnea. But really, I don’t have time to stop and explain to you all the medical reasons for my questions.”

“You really have a condescending attitude doctor! “

I looked at her and wanted to tell her immediately to go jump out the window since I figured it was 10 stories high and therefore would be effective in the job that she needed done.  But I didn’t.  I just stared at her, relatively calmly, thinking of what to do next, knowing that this is a very litigious society; a society that has encouraged patients not only to sue whenever they could, but also that they had a right to sue at any time, and that they should at least report any physician who had a bad attitude to the state board.  Hospitals also aggressively support this reporting to their administration with complaints, hoping to keep their patients happy when they rail against us horrible doctors, who after all, are the enemies of modern society.  So I excused myself, stepped out and left her alone for a little.  I came back with a nurse practioner who pulled up another chair.  I needed a witness.

“Why is she here?”

I didn’t answer.

“So, have you ever been told you have a nervous condition or were treated for anxiety?”

“No, never.  And that isn’t applicable here.”  Then she hesitated as I stared at her.  I stared her down as if she was just a dull rock taking up space, in dire need of being thrown through a window. I wanted her to tell me about her psychiatric problems, because I knew she didn’t need a home sleep study at all. “Well, I guess I was on medications for a time a while back for my anxiety and depression, but that no longer applies now. I don’t have anxiety!

No, she didn’t need a home sleep study at all.  Her problem was psychiatric, but I ordered it anyway.  Why?  Well, the path of least resistance.  Here’s reason number 40 of why the cost of medical care just continues to rise:  Make patients happy to avoid costly complaints to the medical board for absolutely no reason at all.  Then, I would have to get lawyered up, spend hours and hours defending my completely professional encounter with her instead of using my skills to save people’s lives or at least make them better.

“Thank you for ordering the sleep study. After it is done, when will I follow up with you to discuss the results?”

“You’ll follow up with my nurse practioner.”  I knew the study would be normal, and it was.

 

SRC