What Doctors Don't Ask

Daniel Meltzer, MD

Written by Daniel Meltzer, MD

“How are you feeling?” It’s a question we frequently ask patients – on rounds, in the clinic, post-operatively – and with all good intentions and gentility. But, do we ever stop to think: what is really the point of this question? What information are we trying to glean? I think for most of us, we’re asking the question with a cognitive bias towards the physical. How are patients “physically” feeling – better, worse, same, new symptoms, associated symptoms etc.. How will knowing this information then alter our medical decision making, diagnoses and treatment plans – you know, the usual “doctor” stuff…

Do we ever think to consider a different question: How do patients feel? “How do you feel” as opposed to “how are you feeling?” It’s a subtle alteration but perhaps with a powerful twist and a window to deeper connection with, and understanding of, our patients; insights into the physical and the emotional qualities of health and well-being. How they feel as a proxy into the burden of their symptoms. Yes, the postoperative pain may be improving; they may be tolerating their medication; but perhaps they are also afraid, nervous, upset. And if so, does this matter? Does it impact their disease-state? Should we care?

Danielle Ofri’s NYT article, Why Doctors Care about Happiness, describes happiness and health as inextricably linked: “If a patient has poor health and is also feeling miserable, it’s not enough just to address the medical problem. How a person is feeling emotionally needs to be acknowledged and explored.” Furthermore: “[W]e in the health care professions need to notice and inquire about happiness the same way we do other aspects of our patients’ lives…. I don’t presume that these challenges are facile to solve, but hopefully our conversation lets patients know that their happiness matters as much as their cholesterol.”

Connecting to and with patients, on an emotional level, gives us insight into disease management from a more holistic perspective. Health impacts mood, mood impacts outlook and outlook impacts health. Without knowing how patients are feeling, we leave out a vital part of the history. How the patient feels is truly the story and impact of the disease.

So, lately I’ve been asking patients both: how are you feeling and how do you feel, trying to work both into my history. Typically patients freely report their physical ailments – having been programmed accordingly or perhaps, and even sadly, not wanting to burden us with the emotional qualities of their illness. However following up with a “how is that making you feel?”, or “what impact is that having on you and how can I help?” – That’s scary stuff for most of us, and likely, for them. It feels rather “psycho-babbley.” This is almost NEVER something we want to do -- nor feel comfortable doing -- in the ER, I can tell you that. We often think “I don’t have time,” and/or “it’s not my job.”

I suggest you try it. I have and what I’m finding is that patients are not only grateful for the inquiry, they often offer useful pearls about how to best manage their diseases. They begin to more effectively co-partner in their care, cutting to the chase and saving us -- in the long run -- unnecessary, low yield work. The reward of this line of questioning I would submit, both for our patients and selves, outweighs whatever costs we may perceive. And As Dr. Ofri again notes: “Patient’s sense of well-being is something that should definitely register beyond the minor afterthought that it typically merits.” Furthermore, “doctors, of course, can’t solve the economic, societal and interpersonal challenges that cause unhappiness, but attention to the inner sense of suffering is helpful above and beyond our treatments for the disease itself.”

We cannot separate how we are feeling from our feelings. Having hypertension, needing surgery, having to take a new medication are issues in themselves. Being confused, frustrated or depressed about them surely impacts and multiplies the inherent disease burden. We must know about not only the physical but the psychological burden of illness and disease. It is ours to address –not just the spouse, family, friend and therapist. If we are to truly heal, as Maimonides once said, we must seek to “see within each of those in need, only the human being.”

The solution is connecting, alleviating suffering, all through simple phraseology. And, as a result, we learn more about what brings our patients in, why they have come to see us, what they want, and how we can help. Asking pointed and even difficult questions, such as “how do you feel?” and contrasting it with a more typical “how are you feeling?” allows us to improve our diagnostic and therapeutic effectiveness, deepen impact, and on a personal as well as professional level, to feel and do better ourselves.