When the Chief Complaint Tells It All

Following the advent of modern medical technology approximately 40 years ago, physicians gradually shifted their focus from the patient to the laboratory and imaging suite. Consequently, many of today's medical students and house officers, along with some of their teachers, lack the clinical skills necessary for high-quality patient care.^1–3 Among a variety of resultant concerns is the way those individuals approach diagnostic problems.

That approach characteristically begins with the patient's chief complaint. Giving thought to the chief complaint, however, lacks the attention it once commanded. Nowadays, it often serves purely as the trigger for a slew of tests and procedures. To illustrate that point, I occasionally ask medical students and house officers what they would do if I complained that every time I urinate, it thunders. You would think that anyone with common sense could respond appropriately—just have me urinate and listen for thunder. But common sense is uncommon.⁴ Indeed, only about half of the trainees whom I encounter answer my question correctly. The others either do not know what to do or would order various tests, including renal ultrasonography and abdominal computed tomography (CT).

To determine the extent of this problem in the teaching hospital where I work, I created a carefully worded clinical quiz to be answered anonymously by the trainees and faculty assigned to the medical service.

The test group comprised 6 junior medical students, 5 medical interns, 5 medical residents, 4 chief medical residents, and 5 members of the teaching faculty. My primary goal was to see whether any of those tested would attempt to verify the patient's complaint before initiating any type of investigation. I also wondered whether their answers would reflect their level of training and clinical experience.

The woman in the quiz had been a patient of mine during my 2-year tour of duty in the U.S. Air Force 58 years ago. Her husband, an airman, was stationed with me at the same air base. I used exact features from her case to form the quiz. When viewed in concert, those features immediately suggested that her complaint was bogus. First, and most compelling, it was bizarre—one that I had never heard before or since—and not a complaint ordinarily associated with any known disease. Second, she offered no other complaint and felt fine. People with organic disease typically have more than one complaint and usually don't feel fine. Third, she was young and gave no history of any medical problems.

Armed solely with the information supplied in the quiz, I admitted the woman to the base hospital for 24 hours of observation. Although I was confident that her complaint of urinating only once a day had no veracity, I had to prove it. Accordingly, I asked the nurses to document every time she visited the bathroom or requested a bedpan. In addition, I asked the patient to notify the nurses every time she felt the urge to urinate.

As I had suspected all along, the patient urinated more than once during the observation period. In fact, she urinated 7 times and put out a total of 1,700 cc of urine. When confronted with this evidence, she confessed that her husband had been ignoring her and that she had no close friends to talk with in the military housing project where they lived. Desperate, she had concocted a complaint that might bring her the attention she craved.

To complete her work-up, I did a physical examination and ordered a urinalysis, together with determinations of her blood urea nitrogen concentration and serum creatinine level. All yielded normal findings. At that point, I arranged marital counseling for her.

Results of the quiz were telling, with no real surprises. None of the 25 people who were tested, including the 5 members of the teaching faculty, listed specific verification of the patient's complaint as their first diagnostic step. Two of the medical residents, however, came close. One listed a “voiding diary” as the 3rd step; the other mentioned “follow-up in one week with a log of how many times she urinates” as the 5th step.

Another striking finding was the similarity of responses at all levels, from the students up through the teaching faculty. Almost every participant listed more history and a complete physical examination as the first step. From there, the floodgates opened, and a vast number of tests and procedures poured in. Arranged in no particular order, these included bladder scans, ultrasonograms, CT scans, magnetic resonance imaging, a thyroid panel, renal and endocrine consultations, a pregnancy test, a study of urine electrolytes, a renal biopsy, a volume-repletion study, a basic metabolic panel, and others.

These results indicate that those tested failed to understand the true, deep meaning of the patient's complaint. Consequently, they had no idea what was really going on with her. And on the basis of their answers, they would have wasted a lot of time, money, and effort trying to find out.

Moral: Sometimes, the chief complaint tells it all.⁵