Lessons from the other side of the stethoscope - the ROS

The best clinicians I have worked typically speak enthusiastically of how much they learn from their patients. Perhaps because it is (happily) not a daily event, or perhaps because it is so much more personal, clinicians do not talk much about what they have learned from being a patient themselves. The other end of the stethoscope is a good place to learn about medical care.

During the diagnostic phase of my wife’s serious illness (now happily resolved) we received care in a number of offices over an extended period. 

An experience that stands out out as teachable moment for me, and that has impacted my approach to my own patients, was in the office of Dr. Margaret Seton, a tertiary care rheumatologist and international Paget’s disease expert at the MGH.

After taking her own detailed history of my wife’s symptoms, and her personal past and family medical information, she reviewed with us the pile of records she had received and clarified any discrepancies.  Before she moved on to the examination, she said,  “I need to run through some standard medical questions. It’s a list we ask just to be complete. It helps us tie up loose ends, to make sure we have all the details and don’t miss anything. Some of them will make no sense. Please just answer them as best you can. Patients sometimes find these questions confusing or upsetting, so if a question makes you uncomfortable or you are worried about why I am asking, please stop me so I can explain.”

As a physician, I had always found this ‘review of systems’ the most awkward and least comfortable part of the patient evaluation. As patient and spouse, we had been through it before and I always dreaded it. The questions, familiar to me and every clinician, hint at the unspeakable: “Have you had any rectal bleeding? Unexplained weight loss? Trouble with your vision or hearing? Coughed up blood? Sores that won’t heal?” 

My wife and I discussed on the way home how powerful this had been for us. Perhaps it was her reassurance that the questions were from a standard list and did not carry any hidden implications for our circumstances. Perhaps it was her offer to explain (which we did not actually need). Perhaps it was the underlying empathy. Perhaps it was simply that we were forewarned and therefore forearmed by an explicit recognition of the alarming nature of some of the questions. 

I am not sure why it made such a difference, but it did.  Since then I have taken care to explain the process when I have to ask potentially upsetting questions. 


Links to more on this topic::