Doctors are taught to ask about your child’s chief complaint in a very open-ended fashion, such as: “What brings you here tonight?” Busy emergency department doctors, unfortunately, are more likely to glance at the nurse’s note and say something more direct, like: “So tell me about Johnny’s cough.” The ideal situation, though, is for the doctor to begin the interview in a neutral, non-directed way, because questions that are too focused in the beginning can easily lead to … misadventures. Asking parents what their child’s chief complaint is sets the tone for the whole encounter. It is therefore crucial for parents to answer that important question in their own way. An experienced doctor knows this in the abstract, but sometimes in the press of a busy night forgets. No matter how busy the doctor or chaotic the situation, parents need to make sure the doctor hears their own explanation for why they are there.
It is also important, vitally so, to understand what the chief complaint is not — it is not a specific diagnosis, because that implies a conclusion. Many parents, and sometimes busy physicians, fall into the trap of describing the chief complaint in these terms. Perhaps your child has asthma and has needed frequent visits to the doctor for breathing treatments. On this particular night, he is having breathing problems again, and you take him to the emergency department. You have been through this scenario many times before, and the problem has always been a flare in his asthma. When the nurse, and then the doctor, asks why you are there, you say: “His asthma is acting up again.”
That is not the best answer, because it is a conclusion, a diagnosis, not a symptom. Even though you are probably right — it very likely is asthma — the best way to answer the question of “why are you here” is not “asthma;” the best way to answer the question is “difficulty breathing.” My point is that the chief complaint is just that — what the patient is complaining about. What hurts? What does not feel right? What is bothering your child?
The chief complaint is either a symptom, like abdominal pain or difficulty breathing, a physical sign, like a lump on the neck or a rash, or both together, like an itchy rash or a painful lump. In our example, most of the time difficulty breathing in a known asthmatic will turn out to be caused by asthma. But sometimes it will be something else, and it is a mistake to begin the medical history with an assumed conclusion; it is one of the many things that can lead to bad communication between patients and doctors.
Once the doctor is clear on what the chief complaint is (and you should not go on with the interview until you are sure this is the case), the next part of the medical history is called the history of present illness, often abbreviated as HPI. It is a detailed discussion of your child’s chief complaint. The doctor will often begin by asking a parent some open-ended questions like “tell me about the pain” or “describe the rash for me,” but this is the point in the process where the open-ended quality of questioning ends. The doctor has a very controlled agenda, and a parent should not be surprised if she keeps a fairly tight rein on the discussion from this point on. In a sense, the interview moves from the parent-directed chief complaint to the more physician-directed aspects of the rest of the history.
Even though doctors always want to encourage parents to describe their child’s particular symptoms in their own words — it is a huge mistake to put our words into parents’ mouths — what doctors are searching for in the HPI are explicit answers to specific questions. From the viewpoint of a busy doctor, completely allowing parents to take the conversation wherever they like is a recipe for confusion and annoyance, and it can be a huge waste of everyone’s time.
Some parents are naturally better describers of their child’s symptoms. Some give answers so brief they convey almost no useful information, whereas others wander all over the conversational landscape. From the doctor’s perspective, at least a few parents need to be forced, sometimes seemingly against their will, to answer specific questions and answer them briefly. The natural and understandable wish of parents, who sometimes have been waiting for hours, to tell the doctor everything on their mind can collide with the doctor’s need to get key information as efficiently as possible, especially if the setting is a busy clinic or emergency department. I do not mean to excuse doctors who behave rudely, but it is easy to see why a doctor can sometimes appear at least a little abrupt to a parent. Part of the problem is that many parents simply do not know that medical history taking is more than a friendly chat; it is a defined process that must go a certain way if the child is to get appropriate care.
Doctors are taught in medical school the same standard way to zero in on the chief complaint and define it as they take the history of present illness. The details of how to do this vary somewhat with the particular complaint, but the general technique is the same. Using the chief complaint of pain as an example, student doctors are taught to get these items of specific information about the pain from a parent or patient.
Communication Checklist for Parents
1. Before you see the doctor, try to state to yourself in one or two sentences just why you are there. Use symptom descriptions, not disease categories.
2. Write down the sequence of events of your child’s illness. Be as specific as you can about times and dates.
3. For each symptom, write down its quality, quantity, its associations with anything, if anything made it better, and if anything made it worse.
4. Review in your mind the important points of your child’s past medical history, particularly past hospital admissions, surgical procedures, and injuries.
5. Write down any medications your child is taking — what they are, how often, and the dose.
Excerpted from the recently released How to Talk to Your Child’s Doctor: A Handbook for Parentsby Christopher M. Johnson, MD, MA (Prometheus Books, $18.95).
