A patient appointment for a physical could yield a cancer suspicion or diagnosis. An appointment for chest pain could lead to an intervention for domestic violence. A quick visit for a skin rash could land a high school senior in the hospital for a leukemia workup.
In this business we can never assume that a visit will be about what we somewhat callously have been calling the “Chief Complaint”. You have to be prepared to shift gears, sometimes because the patient drops a hint or a bombshell revelation they didn’t tell the scheduler, front staff or medical assistant. And sometimes because you hear, see or palpate something suspicious.
In some ways, we always have to be triaging, before we settle into a “routine” visit. Triage comes from the French word “trier”, which means “to sort” or “to select”.
Primary care is messy. We have to sort who needs something done quickly for a high risk symptom or finding, who needs a different level of care, who needs simple reassurance and who needs a long term plan.
All of this without forgetting the screening and preventive health agendas, which is what we are graded on. There is no formal tool to evaluate our diagnostic acumen. So we are measured for what is easy to measure, the so called “street light effect”.
The Art of Listening: Beyond the Chief Complaint
A doctor’s schedule as typical EMR templates see it only has “Visit Types”: New Patient, 15 minute, 30 minute. But as clinicians we like to know more than that.
Primary Care is Messy
Primary care is a messy business. Nobody has just one simple problem and no patient has all the typical symptoms for their diagnosis. Most don’t even tell us everything that’s going on. And most don’t follow their treatment plan completely. But this may be O.K., since we often change our minds about what is right or wrong in the practice of medicine.