Monday, July 28, 2014

Adding Motivtion for Visit as part of the Chief Complaint

When writing, Dragoning aka dictating, typing and or clicking a classic history and physical exam, there is a traditional format to follow.  What may be left out is the underlying motivation or deeper concern that led to the actual visit.  Most physicians try to discern a "Reason for Visit (RFV)", and there was an academic effort not too long ago to replace the Chief Complaint (CC) with RFV, but CC is too thoroughly entrenched in the medical world.  This effort was driven by recognition that even the most common complaints - say chest pain- have underlying, relevant forces that make an individual decide to go to the ED.  Such forces can include- "MY wife made me come.", "I thought I was going to die.", or "It was about time I did something."- indicating a longer history of symptoms than might initially have been thought.  Of course, there are many, many other motivating forces of this type.

Motivation therefore includes concerns, worries, fears, family pressure, employer pressures, generalized anxieties, and specific desires.  The list goes on and n, and few are irrelevant.

Concerns about a potential serious illness like a stroke or heart attack are often very real and very present.  Eliciting early on in the encounter that the patient was worried about a stroke, for example, adds quick perspective to the evaluation.  Moreover, a very important reason for trying to elicit such concerns is that addressing them is key to patient satisfaction, and proper thoughtful care of individuals.  The patient who is too embarrassed or afraid to say anything leaves unsatisfied because their concerns were not evaluated.  Hence, it is frequently the physician's responsibility to tease these details out, as best as possible.

Another major and related dimension to motivation is the parallel issue of the real reason for the visit.  For example, we often learn that a family member "made me" and we become less interested in the family dynamics than in ascertaining all relevant key information.  This is the time to ask everyone available about what is actually going on.  How many have not seen the patient checked in with a CC of some non-specific somatic complaint- tired, weak etc., only to learn from the wife that he has had repeated exertion chest pain for weeks or months, mowing the lawn or taking out the trash.

Of course, patients often have specific agendas- medications, antibiotics, work excuses, etc. and once discerned and addressed can expedite care.  Once you actually get to the bottom line, beating around the bush ends quickly.

The benefits of asking key questions to elicit the reasons a patient decided to change his or her normal life course and come to the ED will lead to increased patient satisfaction, decreased complaints- the provider never listened to me- and reduction in liability concerns.  Cost savings are often additionally obtained because a focused evaluation solves the main problem earlier, without extensive testing or time.

When eliciting the chief complaint, try to keep the door constantly open for revealing motivation by adding sensitively phrased questions that do not challenge the patient or appear to disrespect their decision to come.  Saying- what are you doing here at 3 am with this complaint that has gone on for 6 months has the potential to put some patients and or families off.  A bit of rewording that acknowledges the human foibles in us all will help get to the bottom and provide reassurance.  Perhaps adding- help me understand what moved you or I know it must have been especially bad this time, can you tell me what was different?  This may help you to where you want to go without offending anyone.  In any case, finding out motivation for showing up will dramatically increase efficiency and accuracy.  It is perceived that the provider Listened and Cared about Me!

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