Secrets that patients carry

When patients come to the office or hospital, they-or their caregivers-usually have a story to tell, beyond the obvious list of symptoms. I've learned the importance of uncovering the "story behind the story," because without it my attempts at diagnosis and treatment might be futile.

This was made clear to me many years ago, when I was a second-year pediatric resident assigned to the outpatient clinic. My first patient of the afternoon was an 11-year-old girl accompanied by her mother. After dutifully recording her medical history and performing a complete physical, I reported to the attending pediatrician in the adjacent room.

"Chief complaint for this 11-year-old is chronic headache," I said. "The history, review of systems, and exam are unremarkable. It sounds like she's having migraines, and I discussed abortive therapy and preventive therapy. Do you need to know more or can you sign off on this one?"

I tried not to roll my eyes. By now, I should have been used to nitpicking attendings with nothing better to do than make my day more aggravating. "Could you perhaps join me in asking these questions so that we can get this visit over a little faster and I can move on to the next patient?" I asked in my most civil voice.

A tragic story emerges

As the attending entered the small exam room, I introduced her to my patient-a perfectly groomed and well-mannered adolescent dressed in her plaid school uniform. Her mother rose to greet us.

"Dr. Scheller told me about your daughter's headaches," the attending said. "I don't want to take a lot of your time, but I need a little bit more information. Can you tell me who lives in your household?"

The mother answered graciously. "Myself, my husband, my daughter here, and her six younger siblings." So, I thought, it's a big family. Did I need to know this?

The attending looked at me and continued. "Does anyone help you look after all those children?"

The mother pointed to my patient. "My daughter helps me feed, dress, entertain, and review the homework of all of her younger siblings. She's so mature, and so dependable." Okay, I thought, that's a lot of responsibility for an 11-year-old. That might contribute to a headache or two.

But the attending wasn't finished. "And is she able to find the time to get her own homework done and to participate in any extracurricular activities?"

The mother beamed proudly. "She's an A student. And she's happy to help me out at home rather than run around with her friends." I was beginning to see the larger picture. Perhaps the young lady is a little stressed, I thought. I certainly didn't have such a full plate at that age.

More questions from the attending. "Is your husband able to help out at home?" I thought, isn't that getting a little too personal?

The mother shook her head glumly. "Unfortunately not; he's disabled and in a wheelchair." Oops! That's something I should have learned when taking the history. Still, was it really relevant to the headaches?

Yet more questions. "How did your husband become disabled?"