Questions and Answers in Medicine

Questions, questions, questions… They are the scaffolding that surrounds any medical encounter. One could almost phrase it semi-mathematically: patient/doctor = question/answer. And the success of the relationship -at least at the start- is largely dependent on the answer part of the equation. Patients usually come armed with both a problem and questions about it. That is natural, but sometimes the latter are as thickly layered as bees around a hive and actually obscure the issue to be addressed. Not all questions have answers; not all problems have solutions -not at first, anyway and sometimes not at all. This seems all too often the case in obstetrics.

Many questions arise out of what seems at first to be mild, symptom-related curiosity: vague, and only occasionally experienced sensations in pregnancy such as, say, leg cramps, fatigue, or maybe even shortness of breath. Most are relatively common complaints, the causes of which are not well characterized and don’t admit of a detailed, scientifically validated explanation. Indeed the answers need sometimes to be experientially based and may therefore vary from patient to patient, and even doctor to doctor -a point readily noted by the more concerned couples who have often consulted friends with similar symptoms.

I have to admit that I sometimes feel evasive, or even fraudulent answering some questions as if I was in possession of the one correct answer: there may not be one. But I know that behind each question is a concern, a fear only thinly disguised with a smile, that there is something wrong with the pregnancy. And of course, sometimes there is, so each question has to be considered in the context of a reasonable differential diagnosis. The leg cramps could herald a phlebitis, the shortness of breath an infection, or even a pulmonary embolus. And nowadays the patient often knows this and seeks reassurance.

And of course, not everything is pregnancy-related: nausea and vomiting could be signs of a viral hepatitis, increased frequency of urination could be a bladder infection… Questions -problems- can be Hydra-headed; to view them in monochrome may be a mistake. There is a balance required: not every headache is a sign of pregnancy induced hypertension, nor every dizzy spell an anemia. Not every symptom is pathological, and as I am fond of telling my patients, pregnancy is not a disease.

Still… To miss something serious is unacceptable -incompetent, even- but to alarm unnecessarily has its consequences as well. There is a middle road, even with complex and alarming questions: it is to listen carefully and compassionately and to consider each query in context. Often the patient doesn’t want a detailed academic answer, just a thoughtful reassurance mindful of her own particular situation. The fact that a concerned stranger on the bus said that she looked a little pale, or perhaps puffy in the face calls for a different level answer than a question about newly acquired cramps early in the pregnancy. That much is fairly obvious.

But what may be less appreciated especially on a busy day in the office is that even trivial questions are asked for a reason. She may, in fact, already know -or intuit- the answer and feel silly bringing it up. But she needed to ask -just in case… And her concern deserves attention, not merely a quick, reflexive reassurance that might seem to her both insufficiently analysed and dismissive. Even pausing briefly before answering suggests a more detailed and therefore considered analysis of her worry.

Answering questions is a skill and one which benefits and matures with experience; one has to be mindful of the reason for the question, as well as the depth of the answer expected. It is an art; it should not be artful -we have politicians for that.

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