Ian Gilson, FACP, an internist who practices primary care medicine in a multidisciplinary clinic in Milwaukee, told us about a 44-year-old married professional woman who was scheduled as the last appointment of his Monday evening clinic. She had a history of asthma and depression, and came in nearly one year after her last appointment because she was running out of her asthma medication and SSRI. The depression was a chronic problem and had been quite well controlled on fluoxetine; this medication, Dr. Gilson said, was a “legacy prescription,” having been given to her years before she came under his care.
When Dr. Gilson asked about her depression, the patient curtly said she was “so-so.” He told us that her tone of voice gave a clear message: “Let's move on.” So he did. Dr. Gilson then explored how she was coping with her asthma, and she said she was doing well on her current medications. He raised again the issue of her single daily cigarette, which was a long-standing topic of conversation.
Normally, the visit would have ended there, with Dr. Gilson renewing her prescriptions and scheduling a follow-up appointment. “But something about that reply of ‘so-so’ bothered me,” he said. Dr. Gilson told us that he has a special interest in mental health as a primary care internist. Three days before he saw this patient, he had led a focus group on the subject of suicide prevention in primary care medicine. “The consequences of severe depression were very much in my mind,” he said.
Retrieving thoughts about a situation based on a recent experience or a dramatic memory is termed an “availability bias.” This shortcut or heuristic likely evolved over the millennia as a way to adapt successfully to decision making under time pressure and uncertainty. The availability shortcut in thinking can lead us astray, as we have written in the past, but it can also work to our advantage in certain situations.
Getting the whole story
Dr. Gilson, then, was especially primed to pay particular attention to the mood of his patient. Her terse answer and definitive tone of voice signaled strongly that she didn't want to discuss the issue of her depression further. So he took another approach: He gave her a PHQ-9 form, which has a series of questions that provide the clinician with insight into the severity of depression and risk of suicide. “I left her alone in the room with the form for a few minutes,” Dr. Gilson said. “When I returned I was surprised to see a high depression score, including anhedonia and self-worth, but I was most alarmed to see her score on question 9, self-harm—thinking of suicide more often than not.”
Debra Roter, DrPH, MPH, a professor of health policy and management at Johns Hopkins University, works as a team with Judith Hall, PhD, a professor of social psychology at Northeastern University. They have analyzed literally thousands of videotapes and live interactions between patients and doctors of many types, not only internists and primary care physicians but also gynecologists and surgeons. Their work provides deep insight into physician-patient communication. They are particularly focused on how a doctor responds to his patient's emotions, and how this response guides the types of questions he asks, and in what tone.
Drs. Roter and Hall conclude that the physician should seek what they term “patient activation and engagement.” As Dr. Roter explained in How Doctors Think, the idea is to make the patient feel free, if not eager, to speak and participate in dialogue. Many patients are gripped by fear and anxiety; some also carry a sense of shame about their disease. Dr. Roter emphasized that even if the doctor asks the right questions, “The patient may not be forthcoming because of his emotional state. The goal of a physician is to get the story, and to do so he has to understand patient's emotions” (How Doctors Think, pages 17-18).
In this case, Dr. Gilson gave the patient time alone with the PHQ-9 form, a strategy that seemed to allow her to focus on her feelings. Her written answer served as an opening to an in-depth discussion with him that uncovered what was hidden. “She had suicidal ideation for months, imagining asphyxiation or taking a drug overdose. I also learned that she had a history of suicide attempts as an adolescent, and was feeling detached from her husband and her child.”
Dr. Gilson recommended that she increase her dose of fluoxetine, which she did, and referred her urgently to a psychiatric nurse practitioner skilled in the treatment of refractory depression. The patient left a message the next day thanking him for the referral.
Dr. Gilson was primed to pay attention to the answer of “so-so” delivered in a tone that was meant to change the subject. He was able to find a way to prompt and encourage this woman to open up to him despite the fear and anxiety that likely inhibited her from doing so initially. “It is fortunate that I gave her the PHQ-9 form and paid attention to the result. It was key to probably aborting a potential suicide.”
Dr. Gilson remarked that it was also fortunate that this patient was the last appointment in his evening clinic. “Had I been running behind, as I so often am, and had she not been one of the last patients in the evening, I may well have skipped it and missed a crucial diagnosis.” We have written before about how time pressure is becoming more and more acute in how we all deliver care.
One foot out the door
It is not only psychiatric symptoms that patients may be reluctant to discuss due to fear and anxiety. In our own practices we have been struck by how many times patients may mention, almost in passing, a lump that they have felt in the breast or the chest pain they had climbing stairs as they are leaving the appointment, with “one foot out the door.”
Physicians need not only to be attuned to the reality that patients may have a hidden agenda, but also to have various strategies to try to unmask that agenda and the time to address issues raised. This can be especially difficult in a busy primary care practice. Despite this challenge, it is deeply gratifying to the clinician to uncover a patient's hidden agenda. “I've been practicing for a long time,” Dr. Gilson told us, “and I still love to do it.”