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Introspections   |    
Chief Complaint
Timothy Twito, M.D.
Am J Psychiatry 2006;163:1502-1503. doi:10.1176/appi.ajp.163.9.1502
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I had a professor in medical school who enjoyed tormenting students. Let’s call him “Dr. Soprano.” Dr. Soprano was head of medicine at the Veteran’s Administration hospital where I had a third-year clerkship in internal medicine. He was an ardent practitioner of the Full Metal Jacket approach to medical education. A nephrologist by training, Dr. Soprano was a son of a bitch by nature. His main virtue was a willingness to be ruthlessly direct, which was also his paramount vice. In the spirit of making us better doctors, Dr. Soprano routinely pulverized our self-confidence into little mounds of dust that he then scattered with a dismissive wave of his hand. How he thought the particles could ever reconstitute themselves into a physician’s functioning ego was unclear. The likelihood is that he never bothered to consider it.

Dr. Soprano conducted a weekly seminar in which some poor wretch of a student would present a patient’s case for discussion. The chief resident selected me as the first sacrificial victim of the new rotation because our team was on call the night before the meeting. “Just read your admit note from the most interesting patient you work up tonight,” he said. “Make sure you discuss the differential diagnosis. Explain the rationale behind your treatment decisions, and don’t let Soprano rattle you.”

I must have blanched, flinched, trembled, or done all three because he patted my shoulder and said with a sympathetic grimace, “Don’t worry. It’s best to get this out of the way early so you don’t need to think about it after tomorrow. Then you can relax and watch your buddies sweat.”

Thus began my night on death row. Was it my imagination or did the other residents and students avoid making eye contact with me? Did I really dream of blindfolds and cigarettes in the few fevered minutes of sleep I stole between drawing blood, answering nurses’ pages, and working up my sole admission of the night, a naval veteran so wizened and hoary that service on the Bonhomme Richard seemed plausible?

The poor man was a wreck. A stroke had rendered him senseless and mute. A fat stack of medical charts chronicled his grim decline toward the grave, stretching back two decades. Now his kidneys produced mere thimblesful of urine, his lungs were no more elastic than a catcher’s mitt, his heart was so baggy that it could function only by encouraging his blood to continue flowing, and his other organs approximated the useless gawking behavior of bystanders at a crime scene.

My job was to assimilate this information and present it in a concise, cogent manner, a task so absurdly Sisyphean that it had the blissful, if misleading, effect of calming me. Perhaps, my poor brain reasoned, Dr. Soprano’s gruffness was less malignant than avuncular, the public face of a kindly grouch whose crusty exterior concealed a heart of gold.

Or not—as I found out when I shambled into the conference room a few minutes early and introduced myself to Dr. Soprano, who nodded curtly and motioned for me to sit next to him. He was a burly man with a thick shock of wavy black hair whose fierce mien dissuaded me from attempting any polite conversation. Instead, I hunched over my notes, eyes lowered obsequiously, as my fellow medicos trickled into the room and either slumped into chairs or slouched against a wall.

“Begin!” Dr. Soprano barked at 9:00 sharp. He pointed a meaty finger at me and commanded, “You! Begin!”

Everything went well—for about 20 seconds. Then I made my first mistake by saying, “The patient is aphasic, so he cannot state a chief complaint; however, his son heard him fall in the bathroom and….”

“Stop! Stop right now!” screamed Dr. Soprano. “The chief complaint is what the patient says when you ask him what’s wrong, not what his son says. You got that? Patient’s words, not son’s words.”

“Yes, sir.”

“So what’s his chief complaint?”

“He doesn’t have one.”

“Brilliant! Absolutely breathtakingly brilliant!” Dr. Soprano glared at me for a moment before breaking into a broad malevolent smile. “Please continue, ‘Dr. Osler.’ Enlighten us!”

Now, you will rarely encounter a more insecure person in his or her 20s than a third-year medical student who must rotate through various clinical services in a hospital, spending a few weeks on surgery, pediatrics, obstetrics, and the like, struggling to act like a doctor while surrounded by actual physicians and actual nurses who know a million times more than the lowly tyro whose white coat and stethoscope give the wearer the appearance of a superannuated trick-or-treater. And because I was an especially diffident, even timorous whelp, the misery I experienced during the remaining 45 minutes of my presentation was punctuated by the apoplectic outbursts of Dr. Soprano, whose final rebuke was to yell, “I hope to holy hell you’ll never be a resident at this hospital!” a misery surpassed only by divorce and cancer surgery in my lifetime.

Several years later, when I was a resident at a university a thousand miles away, I had an occasion to teach third-year medical students the importance of recording a patient’s chief complaint verbatim. One incident stands out in particular. The patient was a lanky unkempt man with schizophrenia who stood in the corridor laughing to himself. Our team approached him, and then we each shook his hand. Then I asked, “‘Wendell,’ what can we do for you today?”

“You can get me a bottle of [iodine] soap,” he answered.

“Oh?” I replied. “And why do you need [it]?”

He grinned and ran his fingers through his hair before saying, “Because I just masturbated.”

“That is your chief complaint,” I told the students after we finished scrubbing up after seeing Wendell. “Be sure you put that in your note.”

“Word for word?” one asked.

I thought of Dr. Soprano, how I wished to God he’d been with us and had shaken Wendell’s hand first. “Yup,” I said, “word for word.”

+Address correspondence and reprint requests to Dr. Twito, Department of Psychiatry, Allina Medical Clinic, 680 Professional Dr., Northfield, MN 55057; timothy.twito@allina.com (email).

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