Evaluating Patients: Three Critical Questions

I've been a Family Physician for twenty-three years, and worked as a Registered Nurse and Nurse Practitioner for years before that. I've been doing health care in some capacity for thirty-nine years, and that doesn't count my days as a teenaged Candy Striper!

So, like many others of my vintage, I've seen many, many patients over the years. I've done many evaluations and heard countless stories.

The trick in medicine, I believe, is knowing when to worry. Left to our own devices -- and the Internet -- we can worry about everything, and that's simply not practical!

So, when evaluating a patient situation, I've distilled my approach down to Three Critical Questions, and I've found these to be invaluable time after time. Here they are:

1.  What is the worst condition this could possibly be?

 I rule that one out, and work down the list from there. That's not always straightforward. After all, not all headaches are aneurysms and not all skin lesions are melanomas. So, given a specific set of symptoms, I try to define what is the worst possibility. Then, I try to find the most rational test to rule out the "worst case scenario," providing that the test does not present undue risk to the patient.

2.  I often ask a patient: "Do you feel sick enough to be in the hospital?"

I have found that patients are excellent at self-triage -- in general. When a patient responds immediately with "Oh, of course not!" or "Absolutely not," I feel reassured. On the other had, if a patient says "I'm not certain," or "I have been wondering about that," I am ready to look further. A corollary to this, of course, is "Does the patient LOOK sick enough to be in the hospital?" We make these judgements from across the room sometimes! And with children, the key question is "Are they ACTING normally?"

3.  The third, and most important question in medical decision-making is "What are the facts?"

Sometimes a patient and I will simply list the facts we know -- separating the worry out from the facts of the case. For example, a patient may complain of chest symptoms but be capable of doing an hour of high-speed cycling. Does that rule out the possibility of cardiovascular disease? No, but the fact that the patient has excellent exercise tolerance is greatly reassuring. The fact that a patient's work is not impacted by symptoms, the fact that a patient is not awakened by symptoms, the fact that a headache is easily relieved by a Tylenol tablet -- are all reassuring to me. And, of course, we have the facts of the objective data we gather, e.g. laboratory tests and medical imaging studies.

In medicine, there are no guarantees: it's medicine, not accounting!

But I've found great assistance in a quick review of my three critical questions: 1) What's the worst possible case?, 2) Does the patient judge himself to be sick, and 3) What are the facts? After all, a little logic never hurt. Common sense, we know, can be UNCOMMON in medicine!

Take care. Linda Gromko, MD