The Art of Asking the Right Question

I saw Jean in the ER. She was a 25- year-old recently married young woman who had right-sided back pain and was presently on oral contraceptives.

I asked Jean, “Do you have shortness of breath or pain when you breathe?”

She said, “No, I don’t.” I thought for a few seconds about my answer being only as good as my question and knew I was going down the rabbit hole. I had to rephrase the question because I didn’t like the answer.

With my differential running through my head I was thinking of all the possible diagnoses, benign and a little bit benign, like pyelonephritis. Lung sounds were clear. No kidney tenderness, but I thought, what’s the worst thing this could be?  A pulmonary embolus. That was the worst. So, I asked, “Are you short of breath when you walk up the stairs?” Jean answered, “Yes.” I ordered labs including a complete blood count (CBC), urinalysis, D-Dimer, and a  comprehensive metabolic panel (CMP). All tests came back normal except for the D-Dimer, which was elevated.

 So, I ordered a CT (computerized tomography) chest angiogram, which revealed multiple pulmonary emboli. The radiologist said there were so many emboli that Jean couldn’t have survived one more embolus. I gave Jean the first Lovenox injection to begin immediate treatment of the multiple pulmonary emboli. Because Jean was young and otherwise healthy, and because she had so many pulmonary emboli. I sent her off to a hospital where they could at least do an embolectomy. As it turns out, the doctors there didn’t want to do an embolectomy. They treated her with Lovenox and she did well.

In those days we could still test for and treat methylenetetrahydrofolatereductase (MTHFR). There are many versons of MTHFR, but some are more troublesome than others. As it turns out, Jean had a high-risk MTHFR which we treated with warfarin. The testing for MTHFR at this time is not only controversial, but considered completely unjustified. I understand that we are supposed to no longer do MTHFR labs for diagnoses. However, I happen to live in an area where 40 percent of the population has some version of MTHFR. My experience with MTHFR is that many people have a harmless variety, but some do not. There are people who have continued to have strokes, heart attacks, deep vein thrombosis (DVT), pulmonary emboli, and repeated pregnancy loss. When MTHFR is identified, these patients do fine when they’re treated with Lovenox during pregnancy or with coumadin or the more expensive and newer versions of coumadin when they aren’t pregnant.

This was a lesson for me to practice what I had been teaching to my students and residents. I had to ask the right question. I knew that Jean’s answer was only as good as my question. I also know that if I weren’t aware of the diagnosis I would never have thought of it or found it, another valuable lesson. Often history taking is just a matter of listening, but for the most part, taking a good history is an active process. I am responsible for getting the correct answer. I can’t blame my patient for not giving me the right differential.

During residency I learned the art and value of good history taking. The history guided our physical exam, our labs and other tests, diagnoses, treatments and prognoses. Sara presented to the ER with right lower quadrant pain. Sara said, “I’ve had pain lower abdominal pain on the right side for two weeks and have seen three doctors who checked me for socially transmitted diseases (STDs). They said nothing was wrong. I’m not running a fever, but I feel cold at night.”

Sara’s labs were, strictly speaking, “normal.” Her white count, which we would expect to be elevated with infections was, at 9200, not elevated. Sara and I talked about the risks and benefits of laparoscopy. I did the laparoscopy with no complications and discovered a large pus tube on the right. Rather than remove the tube, I hospitalized her for one week’s worth of in-hospital IV antibiotics, which was the standard treatment at that time. Sara did well without complications.

The value of the old-fashioned patient history, even forty years ago ,was sometimes hard to justify with the advent of “evidence-based” medicine. The “evidence” would have dictated that the “normal white count” wasn’t enough “evidence” for a tubal infection to justify a laparoscopy (diagnosis) or treatment (IV antibiotics).

There are many subtleties of successful treatment for pelvic infections. Initially, when treatment is best and cheapest, diagnosis is hard to make on labs because the infections are walled-off and therefore don’t raise a white count very much, often not out of range of normal. Eventually, the walled-off infection can start to leak, and then the infection, although much easier to diagnose, becomes much harder to treat.

Unfortunately, today, the idea of taking an active history and getting the correct answer (diagnosis) is threatened by the burgeoning role of the EMR (electronic medical record). EMRs collect small, overly-detailed pieces of information loosing the relationship between bits of data. The EMR has become so time consuming and “important” that all too often the patient takes a back seat and the importance of asking the right question gets lost. 

With a half hour visit, ten minutes go to the patient and twenty minutes go to the chart. To make matters worse, we are supposed to see more patients for less money. If our goal is to destroy health care, we are doing a great job. Today, more than ever, we need take back our valuable histories, physicals, and courage. Let’s resist the effort to replace the patient with the EMR. Good history taking requires time and care, and should not be interrupted or destroyed by minutia.  

Today, more than ever, we need to concentrate on asking the right question and getting the right answer.