William Cayley: My Chief Complaint

bill_cayley_2My chief complaint . . . is with the chief complaint.

One of the hallowed concepts in medical history taking and documentation is the “chief complaint.” Supposedly a way to set the agenda for a medical visit, in current practice it often gets both distorted and treated as a boundary setter.

Ideally, in medicine, we hope to address our patients’ medical problems and cure their ills; and thus we obviously want to know why someone is spending his or her time coming to see us. In modern computer enhanced, team based care, however, the “chief complaint” often becomes further and further removed from what is actually on the patient’s mind.

Computer based (and before them, paper based) templates, pathways, and SmartSets—ostensibly designed to serve as memory prompts and avoid overlooking key pieces of care—all require a “chief complaint,” so that we know what template or pathway to use. That “chief complaint” may come from what is entered into a schedule when the patient books a visit, or from the first thing mentioned when a patient is in the consultation room. The “chief complaint” then triggers a pathway—and we all dutifully follow that pathway, sometimes whether or not it really addresses the problem with which the patient is concerned.

As helpful as templates and pathways are, when we organize our care around addressing a template prompted by a complaint, we end up addressing the issues covered by the template, and not necessarily what brought the patient in to see us in the first place.

I recall seeing an emergency room visit summary, which concluded that “the patient’s chest pain was not chest pain.” (That was probably a surprise to the patient, whose chest still hurt.) What was probably intended by this was something along the lines of “the patient’s chest pain was not cardiac,” but the template led to a premature closure of thinking, and chest pain became equated solely with coronary artery disease.

A study published in JAMA 15 years ago found that physicians often redirect patients’ initial descriptions of their concerns, and, once this has happened, the patient’s original descriptions are rarely completed—I fear templates have only made this worse.

The “chief complaint” as listed in the schedule for the day, or in the list of concerns given to clinical staff, may also end up becoming an artificial boundary setter. If we think of the visit with the patient only in terms of the listed “chief complaint,” we may miss the other things that need to be addressed.

Frequently, one sees articles on how to deal with “hand-on-the doorknob” questions (those that arise as we have our “hand on the doorknob” to leave the consultation room), or with the patient who brings in a (“dreaded?”) list. The unspoken implication here seems to be that the consultation is getting out of control—the patient has more concerns than we have the time, energy, or desire to handle—or that the visit has in some other way become something more than we (the medical professionals) bargained for. Perhaps though, if we placed a higher priority on discerning our patients’ true concerns, we’d do a better job of addressing those concerns, and be less frustrated by lists or “doorknob” questions. (Often, the patient with a “list,” if given adequate freedom to explore that list, will give us a better history than we’d get with our sometimes overly focused questions.)

Prioritization and agenda setting are important if we are to be sure that we cover what is on the patient’s mind. But, if we hope to provide medical care rather than simply fit our patients to a template, we need to be ever mindful of seeking out each patient’s concerns (or complaints, or problems, or issues, or whatever other word you choose to use).

The “chief complaint,” as it often gets used in today’s medicine, is sometimes a far cry from the original concept of figuring out what is causing a patient to feel ill or to suffer. Fundamentally, it’s not about a “reason for visit” or some other categorical label: it’s about understanding the patient in front of us.

William E Cayley Jr practises at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: “I declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare.”