The minimalist approach to medicine

The other day, I had cause to sit in on a medical appointment.  I’ve sat in on lots of medical appointments over the years, but this was one of those relatively rare times when I was there because of my relationship with the patient, not in a professional capacity.  Though it’s impossible to dissect away my medical persona from the rest of my psyche, I experienced the visit more from her perspective than as a doctor.

During the history-taking part of the appointment, the medical provider asked a few pointed questions about the patient’s social situation, which had no direct relevance to the reason for the visit.  Hearing these questions, my thoughts diverged.  As a physician, I knew immediately why the questions were asked, and what the medical provider was trying to accomplish by asking.  She wanted to know that the patient was “well” in a more general way than just pertained to the proximate medical concern.  I understood the goodness in her intentions.  But I also could see that the patient found the questions both invasive and condescending.  Further, as much as I could grasp the reason for the questions, I suspect that was only because I’ve been on the other side of the provider-patient relationship.  For any given patient, the questions would (and did) seem to come from out of the blue.

It was this vein of questioning (albeit about the unrelated subject of gun ownership) that rankled Ken at Popehat a little while ago, and in response I went to bat for asking them.  I haven’t changed my mind about asking questions related to social situation and risk factors and all the rest of it in the few short weeks since I wrote that piece.  If we are meant to treat our patients as complex and multidimensional human beings instead of a collection of medical problems, it is important to have a sense of their lives as a whole.  As a pediatrician, part of what I’m supposed to do is offer anticipatory guidance about keeping kids safe and healthy.  Indeed, as a specialist in adolescent health I ask about specific kinds of risk behaviors in a confidential manner, because it’s both directly relevant to my patients’ health and often something they don’t tell other people for fear of being disciplined by disapproving parents.  (I’m not so naive as to believe they always tell me everything either, but at least I give them a space to do so “safely” if they’re inclined to be honest.)


I think the importance of asking questions intended to mitigate risk of injury or disease must be balanced against respect for our patients’ ability to take care of themselves.  There seems to me a tendency within the medical community to view ourselves as all-purpose dispensers of invaluable advice, which if taken will obviate problems our patients would otherwise not know how to fix. We must ask about everything, because we must be prepared to instruct in all things.

This is, of course, arrogant hooey.  I was a happy dispenser of this kind of advice for several years before I had a child of my own, and have (half-)jokingly commented many times since getting the Critter that I feel like I should call several years’ worth of parents and apologize for being so bloody worthless.  A startling number of areas in which I was wholly ignorant surfaced, despite having handy answers provided by the AAP.  A lot of the advice I give now is informed by my experience as a parent, not as a physician, and could have just as easily been given by a kindly aunt.

I try to keep my advice limited to a few discrete topics for each stage of development.  I remind parents of small infants that their children could start rolling over soon, so to be wary of leaving them unattended on flat surfaces.  I make sure I discuss concussions with any patient who plays tackle football.  I review contraception with all of my adolescent patients.  Etc.  And obviously I give advice about specific subjects when I’m asked.  I would be doing a half-assed job if I didn’t, and (to paraphrase America’s greatest avatar) I like to think I use my whole ass when I’m working.  To take  a “see no evil” approach (which is, frankly, how a lot of pediatricians deal with their teenage patients) is to be a lackluster doctor.

But the other extreme is to be avoided, as well.  With this pervasive tendency in our society at large to medicalize every problem or quirk, seeking a medical solution when the answer (if there is one) lays outside the doctor’s office.  I think much of this comes from unrealistic patient expectations, but physicians and their professional organizations play no small role either.  (There will never be a more perfect example of this tendency taken to a ridiculous extreme than the lamentable calls to redesign the hotdog.)  We don’t have all the answers, and can be just as susceptible to faddish nonsense as anyone else.  (You can color me skeptical about all the health claims currently being attributed to vitamin D, which I strongly suspect will be the “oat bran” of its time.)

Should we give helpful advice?  Of course.  Should we ask questions of our patients to better know their lives and better understand their health?  Certainly.  Should we probe our penlights into every last little crevice of their habits and households?  Perhaps not.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Recently, we saw a doc in our practice who is one we don’t normally see. She asked what our income was. I was SERIOUSLY pissed off, offended, and felt it a serious invasion of privacy.

    • I am totally incapable of constructing a clinical scenario that justifies that question having been asked. Mmmmmmaybe if she had been discussing a very expensive treatment or test that might not be covered by insurance it would have been appropriate to respectfully inquire if cost would be prohibitive, but to just ask about income outright? Appalling.

      • Context was simply that we had a severely disabled kid. In for a follow up on some minor issue of the ear infection sort. Obviously possessing equipment such as AFOs, wheelchair, and feeding pump; and obviously insured (since his medical history has about 17 subspecialists listed and several surgeries).

        I LOVE other docs in the practice and don’t want to stir up anything. I just avoid her where possible.

        • yanno, this is why i’d let the person know, anonymously, if possible.

          I wasn’t there. But I can be remarkably thickheaded, so I always hate folks talking behind backs when a straightforward and blunt TWUMP might make a difference.

    • I’d drop an anonymous (possibly handwritten) note to the secretaries. This seems mostly a problem of “utter lack of tact” rather than any malicious intent. And the doc ought to be called on that, and trained in “what may be asked, and what may not be asked…”

    • If I over stepped boundaries like that with a patient, I would rather be told that out was none of my business than let the insult fester.

      • exactly. the people blunt enough to do that, and not meant it as an insult? they want their noses slapped like you do a puppy’s. No harm, no foul, but make sure they get the message.

  2. Dr. S–
    Please feel free to dispense advice to us at any time. Your Critter and ours share so much in common, you’ve gotta pass on the gems.

  3. During the history-taking part of the appointment, the medical provider asked a few pointed questions about the patient’s social situation, which had no direct relevance to the reason for the visit. Hearing these questions, my thoughts diverged. As a physician, I knew immediately why the questions were asked, and what the medical provider was trying to accomplish by asking. She wanted to know that the patient was “well” in a more general way than just pertained to the proximate medical concern.

    Do you think it would help for the physician to explain to the patient their reasons for asking the questions?

    • Yes, I think it would go a long way. If people can simply understand why you’re asking, then I suspect they’re less likely to feel intruded upon or condescended to.

  4. There’s a simple, humane rule of thumb for such questions: when you’re trying to get to the bottom of a problem, always start by explaining why you need to ask the invasive question in the first place. Wait two seconds. If the interviewee starts to bridle, let them get it out of their system: they know what’s coming. It won’t take long. Don’t assume a power position, explain you’re trying to rule out something and why it’s an important question. When they start explaining, do have the decency to pay attention and sympathise. If necessary, reassure them after they’ve answered.

  5. I was fortunate enough to have an assistant teacher who was a parent and who rightfully called me on instances where I gave advice that seemed perfectly reasonable from the perspective of someone whose sole interaction with children was in a carefully controlled environment designed specifically for children but which was perfectly unreasonable from the perspective of someone who had to interact with their child while getting dinner ready and doing laundry and paying the bills and had already worked an 8 hour day. It was an important check she put on me, one I try my best to be conscious of when I speak with parents. At this point, I tend to go so far as to say that A) I’m not a parent and B) I know much of what I offer is easier to say than do, for the reasons mentioned above, and they are right to want to punch me in the nose and tell me to call them back when I have a kid of my own.

    Before Gutcheck- “Just wait out tantrums. If you give in to them, it only encourages the behavior.”
    After Gutcheck- “I have the privilege of waiting out a 20 minute tantrum because I get paid to and where the hell else do I have to go? If buying the cookie is the only way to get out of the store in less than an hour and you’re already late and everybody is staring at you and the dry cleaner closes in 3 minutes? Go for it. Just avoid making a habit of it.”

  6. Is it possible that your presence was a factor in the patient’s discomfort? Maybe they would have been happy answering questions with the doctor if they had an established relationship, but the presence of an unfamiliar third party can quickly change that dynamic.

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