Pain and Prompting

Advertisement for curing morphine addictions f...

Image via Wikipedia

It’s funny how you can walk into a room, think you have a pretty clear history of what’s going on with the patient, and 30 minutes later your attending comes up saying, “No, he’s telling me it was crushing substernal chest pain with trouble breathing, NOT 2 seconds of pain when he moves his left arm.” Yessirree Bob, the attending effect is real: but I’d like to challenge its origin.

First, some disclaimers: some patients are, simply, crazy. (And I’m not talking psychiatrically crazy, I’m talking dramatic, emotional, over-the-top, and hard to pin down on a clear story. Okay, maybe psychiatrically Axis 2.) And some doctors are, simply, bad listeners. They will never get a good history, because they don’t know what questions to ask, or how to ask them, or how to tease out the important parts of the story from the rest. But besides these caveats, I’d like to hypothesize this: the attending effect is primarily due to pain, or prompting.

Pain’s an easy one. We see this all the time. You have a patient in pain, or nauseous, or angry, or — in any way, emotional — and you might as well kiss most of your history-taking goodbye for the time being. This is no Mt. Everest for us in the ED. This is just how it goes. You get a little story, you treat the pain, you start your workup, you go back once the morphine’s kicked in, and you get some more story. The more calm and rational the patient is able to be, the better history you’re going to get. I find this to be the case all the time when I’m admitting patients: the history of present illness I’ve initially written has evolved over the course of the stay. I’d like to also posit that this is why the medicine resident comes down and thinks I’m an idiot: the story they get from the patient sounds nothing like the one I documented in the chart. (Other possibility: I am actually an idiot.)

“Prompting” is the other big cause (in psychology, they call it “priming“): when you do the initial history and ask the initial questions, the patient may not remember every detail of his or her history. You zip in, get your story, do your exam, zip out, and start writing your orders, while the patient in the mean time has a chance for those questions you’ve asked to simmer a bit in their cranial Crock Pot. Case in point: 28 year-old guy in the ED last night with urinary obstruction. Said he’s never had an STD that might predispose him to this. Urology comes in after multiple failed attempts to Coudé the poor guy, and he freely acknowledges having chlamydia a few years back. So thank you, Urology, for the consult, but I swear we’re not lying: we just primed his brain to remember!

So there’s no reason to be ashamed if you get a different history from someone else — especially if their history comes later than yours.

That is, of course, unless you’re an Axis 2, crazy, dramatic, bad-listening doctor.

  1. #1 by JR - January 4th, 2011 at 09:39

    Graham in a few months we can let you in on the attending “mind trick” which is much like the Jedi mind trick. You are almost ready my young Padawan!

  2. #2 by is edubirdie legit - May 15th, 2019 at 15:06

    It’s hilarious how you can walk into a room, assume that you have a pretty clear history of what’s happening with the patient, and 30 minutes later your presence comes up saying. Do you think is edubirdie legit good? No, he’s telling me it was devastating substernal chest agony with trouble breathing, NOT 2 instants of pain when he changes his left arm.

  3. #3 by concrete contractors - October 17th, 2019 at 11:43

    This is legit true. Patients can really be too emotional sometimes.

  4. #4 by tent rentals york pa - October 17th, 2019 at 11:48

    The stigma is one of the biggest barriers. I have been treated like a lowlife by medical people when I disclose that I have chronic pain and use opioids for it.

  5. #5 by concrete yuma az - October 17th, 2019 at 11:50

    The reasons are complex but must be addressed now. First, humans are social animals who look to their peers to maintain the group’s cohesiveness and stability. This stability includes feeding and protecting the group from external assaults.

  6. #6 by Steve Jennings - March 9th, 2020 at 16:28

    We see a lot of patients that want to avoid pain at all costs, that’s why we’ve specialized in non-invasive body sculpting. Check us out when in SoCal.

  7. #7 by paul - August 10th, 2020 at 13:21

    I know what you mean, it’s like please just tell exactly what’s going on!

  8. #8 by Jacob - August 10th, 2020 at 13:24

    I unfortunately have had numerous patients attempt to obtain opioids from me. It seems to be a bigger issue than it ever was before.

  9. #9 by Monat - August 12th, 2020 at 05:41

    Pain level is high or not?

  10. #10 by Gerald - October 7th, 2020 at 10:44

    In my experience it is of high importance to allow a patient to reflect on questions regarding their pain before answering. When I don’t allow them this time they’ll often contradict themselves later.

  11. #11 by Sarah - October 7th, 2020 at 10:46

    What kinds of pain medication do you find yourself most often prescribing?

  12. #12 by alicja - October 21st, 2020 at 01:25

    Fully enlightening article! This is incredibly a reasonable article I need to express your article is great since you are intertwined.

  13. #13 by jainakapoor - October 21st, 2020 at 01:25

    I need to express your article is great since you are intertwined
    different sorts of a historic point with a remarkably supportive data in have blog. Truly I energetic to look at your blog.

  14. #14 by daniyal abbas - January 8th, 2021 at 01:26


(will not be published)

  1. No trackbacks yet.