Patient Communication

Chief Complaints

One of my senior partners tells a story where he is called out of a patient room to take an urgent phone call. The patient in the room was in his mid-60s and had spent the last 15 minutes describing the 10/10 severity of his lateral epicondylitis symptoms. On the phone was a former fellow, now practicing in a remote area, who found himself suddenly called upon, as the only microsurgery-trained surgeon for hundreds of miles, to replant the scalp of a bear mauling victim. My partner talks his colleague through the case, gives him whatever pearls there might possibly be for such a situation (I suspect none), then goes back into the room and jumps right back into hearing about his patient’s lateral elbow pain.

You’re probably smiling right now, because we have all been in situations when a patient’s experience of symptoms exceeds what we might expect it to be, or, more condescendingly, think it should be. I doubt the bear-mauling patient had access to a VAS pain scale, but many patients with ganglion cysts, trigger fingers or tennis elbows report 8/10 pain or even greater. If you don’t believe me, just start checking your new patient intake forms or asking them yourself.

As a resident, I remember Dr. David Ring emphasizing the difference between pathology and symptoms, the former being the objective departure from normal and the latter the patient’s subjective experience. It can be frustrating as a surgeon when symptoms seem more than they should be. It can be easy to be dismissive, to tune out, to interrupt. But these are opportunities for compassion. For the patient in front of you, these symptoms have risen to the level that they merit medical intervention. That’s why patients have chief complaints and not chief diagnoses. For as long as medical documentation has existed, we have acknowledged in this small way, that what matters to the patient is what needs to matter to the physician. What you medically offer should never exceed the objective pathology, but what you offer emotionally should be titrated differently.

Dr. Andrea Bauer wrote a wonderful JHS Focus Blog about patient communication (Patient Communication 101, September 2016) and I think these types of encounters are when communication is our most important tool. Patients’ symptoms merit validation, but it is well known that psychological distress can amplify musculoskeletal complaints. Sometimes, allaying that stress is the best treatment. Communicate carefully and be sure that your most reassuring points are emphasized. “I understand your tennis elbow is severely painful-it is a common problem and many people experience substantial pain. The good news is that the vast, vast majority of cases resolve, and this will not be a life-long problem.”

Like many of you, I would feel much more comfortable tackling a complex surgical reconstruction, but sometimes we’re called upon not as technical surgeons, but as caring physicians.

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Dr. Ryan Zimmerman is a Hand, Shoulder and Elbow Surgeon at Greater Chesapeake Hand to Shoulder and an Attending Surgeon at the Curtis National Hand Center in Baltimore, MD.

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