When a patient presents with a new symptom, we quickly and almost unconsciously create a hierarchy of diagnostic possibilities. I pride myself on my ability to effectively share my work process through these types of clinical algorithms.

But sometimes I feel like I have non-verbal cues of dissatisfaction or just no reaction at all to my eloquent reasoning. And only then do I remember to ask the important questions, “do you have any ideas as to what is causing this” and, most importantly, “what is your biggest fear than it could be”.

It doesn’t matter how brilliant you are a diagnostician if a patient with less medical knowledge than you has the thought, fear, or premonition that diseases and symptoms are working in ways that don’t make sense to you.

An uncle may have had a burning sensation in his nose a few minutes before a stroke, so this symptom may seem like a much more obvious warning sign of disaster for your patient than for you. How would you know, if you don’t ask the question, what is the first question your patient wants answered?

We are often so focused on our own thought process, especially with our time constraints and the bureaucratic demands of medical appointments these days, that we risk forgetting that our patients may not think like us.

Of course, sometimes things work in the opposite way: the patient may think that they just have something simple, like the woman i saw with sore throat who ended up receiving a cardiac stent for a major coronary blockade.

It is therefore not always easy to ask the question of the “greatest fear”. It is a call to judgment that requires special attention: observe your patient’s facial expressions and body language, listen carefully to their words and the character of their voice.

Basically, ignore the main complaint listed first, ask an open-ended question, then shut up and let the patient talk without interruption so you can listen and observe.

Hans Duvefelt is a rural family physician born in Sweden in Maine. This article originally appeared on his blog, A Country Doctor Writes, Here.

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