{"id":32347,"date":"2014-09-18T14:33:46","date_gmt":"2014-09-18T13:33:46","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=32347"},"modified":"2015-09-22T14:34:31","modified_gmt":"2015-09-22T13:34:31","slug":"william-cayley-my-chief-complaint","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/09\/18\/william-cayley-my-chief-complaint\/","title":{"rendered":"William Cayley: My Chief Complaint"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-31912\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" alt=\"bill_cayley_2\" width=\"202\" height=\"250\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg 243w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg 551w\" sizes=\"auto, (max-width: 202px) 100vw, 202px\" \/><\/a>My chief complaint . . . is with the chief complaint.<\/p>\n<p>One of the hallowed concepts in medical history taking and documentation is the \u201c<a href=\"http:\/\/en.wikipedia.org\/wiki\/Presenting_problem\">chief complaint<\/a>.\u201d 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.<\/p>\n<p>Ideally, in medicine, we hope to address our patients\u2019 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 \u201cchief complaint\u201d often becomes further and further removed from what is actually on the patient\u2019s mind.<!--more--><\/p>\n<p>Computer based (and before them, paper based) templates, pathways, and SmartSets\u2014ostensibly designed to serve as memory prompts and avoid overlooking key pieces of care\u2014all require a \u201cchief complaint,\u201d so that we know what template or pathway to use. That \u201cchief complaint\u201d 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 \u201cchief complaint\u201d then triggers a pathway\u2014and we all dutifully follow that pathway, sometimes whether or not it really addresses the problem with which the patient is concerned.<\/p>\n<p>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.<\/p>\n<p>I recall seeing an emergency room visit summary, which concluded that \u201cthe patient\u2019s chest pain was not chest pain.\u201d (That was probably a surprise to the patient, whose chest still hurt.) What was probably intended by this was something along the lines of \u201cthe patient\u2019s chest pain was not cardiac,\u201d but the template led to a premature closure of thinking, and chest pain became equated solely with coronary artery disease.<\/p>\n<p>A <a href=\"http:\/\/jama.jamanetwork.com\/article.aspx?articleid=188387\">study published in <em>JAMA<\/em> 15 years ago<\/a> found that physicians often redirect patients&#8217; initial descriptions of their concerns, and, once this has happened, the patient\u2019s original descriptions are rarely completed\u2014I fear templates have only made this worse.<\/p>\n<p>The \u201cchief complaint\u201d 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 \u201cchief complaint,\u201d we may miss the other things that need to be addressed.<\/p>\n<p>Frequently, one sees articles on how to deal with \u201c<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/16033602\">hand-on-the doorknob<\/a>\u201d questions (those that arise as we have our \u201chand on the doorknob\u201d to leave the consultation room), or <a href=\"http:\/\/www.aafp.org\/fpm\/2009\/0500\/p23.html\">with the patient who brings in a (\u201cdreaded?\u201d) list<\/a>. The unspoken implication here seems to be that the consultation is getting out of control\u2014the patient has more concerns than we have the time, energy, or desire to handle\u2014or that the visit has in some other way become something more than we (the medical professionals) bargained for. Perhaps though, if we placed a\u00a0higher priority on discerning our patients\u2019 true concerns, we\u2019d do a better job of addressing those concerns, and be less frustrated by lists or \u201cdoorknob\u201d questions. (Often, the patient with a \u201clist,\u201d if given adequate freedom to explore that list, will give us a better history than we\u2019d get with our sometimes overly focused questions.)<\/p>\n<p>Prioritization and <a href=\"http:\/\/www.aafp.org\/fpm\/2002\/1100\/p63.html\">agenda setting are important<\/a>\u00a0if we are to be sure that we cover what is on the patient\u2019s 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\u2019s concerns (or complaints, or problems, or issues, or whatever other word you choose to use).<\/p>\n<p>The \u201cchief complaint,\u201d as it often gets used in today\u2019s 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\u2019s not about a \u201creason for visit\u201d or some other categorical label: it\u2019s about understanding the patient in front of us.<\/p>\n<p><em><strong>William E Cayley Jr<\/strong>\u00a0practises 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.<\/em><\/p>\n<p>Competing interests: \u201cI declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"<p>My chief complaint . . . is with the chief complaint. One of the hallowed concepts in medical history taking and documentation is the \u201cchief complaint.\u201d Supposedly a way to [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2014\/09\/18\/william-cayley-my-chief-complaint\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5749,1357,14769],"tags":[],"class_list":["post-32347","post","type-post","status-publish","format-standard","hentry","category-patient-perspectives","category-us-health-care","category-william-cayley"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>William Cayley: My Chief Complaint - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2014\/09\/18\/william-cayley-my-chief-complaint\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"William Cayley: My Chief Complaint - The BMJ\" \/>\n<meta property=\"og:description\" content=\"My chief complaint . . . is with the chief complaint. 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