Reader Poll


So I had a problem with a patient and family recently and I’m looking for solutions from everyone who reads this blog.

An elderly patient who lives at home with his wife, his son, and his son’s family was brought by the ambulance to the emergency department for “not feeling well.”
As I attempted to get more of a history about the patient’s symptoms, the discussions angered the family.
“When you say that you don’t feel well, what do you mean?”
“I’m sick! That’s why I came here so you could tell me what’s wrong.”
“But I don’t understand what you mean when you say that you’re ‘sick.’ Do you mean that you’re nauseous or you’re having pain or you’re feeling weak?”
“No, none of that.”
The daughter in law then stood up next to the bed and firmly said that he “just doesn’t look right.”
That didn’t help me much, so I said “I’ve never seen him before, so I don’t know where to begin in finding out what is wrong. What about him doesn’t look right to you?”
She threw her arms up in the air and rolled her eyes. “What do you want me to say? He doesn’t look right.”
No, I didn’t grab his head, turn it to the right and say “There … problem solved.” I just stopped asking about his symptoms.
“OK, well how long has he not been looking right for?”
“Oh, it’s been a while now ….”

After about 15 minutes, I was able to determine that the patient was sleeping more than usual for anywhere between 3 days and a week, depending on who was answering my questions.

After I left the room, the nurse told me that the whole family was upset with me because I was being “difficult.”

So the questions I have for you all are the following:

1. If you’re in the medical field, and a patient/family provide you with a vague history, do you try to find out more information? If so, what approach do you use?
2. If you’re not in the medical field, how would you suggest that a health care provider respond to you if the information that you are giving them isn’t helping them figure out what may be wrong with you?

I think that these are questions that a lot of people would like to know, so please chime in below.



  1. It’s no use talking to the family or the patient, as their goal is for the patient simply to be admitted.

    They don’t really care what you find or don’t find, they want the patient admitted so they can run more tests and get granther back to 100%, hard pecker, 20/20 vision, lungs of a newborn. Anything less is malpractice.

    Families like this have given up any semblance of personal or familial responsbility – they just want what they want and want it now. But the problem is, is that they don’t really know what they want, but it’s not their responsibility to figure it out. It’s yours.

  2. Not in medicine, in the computer field, and frequently have to diagnose problems with nonsensical clues, “I clicked on the thing and now I don’t know where it is.”, “My internet isn’t working, can you do that remote thingy that you did before? Ma’am, if you can’t get on the internet, I can’t remote in to it.”

    So I ask them to show me the problem, if they can’t tell me the problem. An astonishing number of people these days have almost no verbal ability beyond, “Uh-huh” and “I’ll have fries with that.” Try asking them to show you the problem.

  3. Hey, when we have a room full, one of the first questions we ask is “Who spends the most time with the patient?”. At that point, we ask the others to step out while we try to complete the assessment. Most of the time, we do get grumbles and the ole “I’m not leaving”. But, we assure them that they can come back in just a few minutes. In the interim, we direct the questions to the person who seems to be the “caregiver” and the patient. This SEEMS to help with the negativity towards the health care provider and the focus can remain on the patient and not the crowd. Easier said than done, I know. But it does help.

  4. Not a medical provider, but also not an idiot (which is what the family sounds like).

    I agree with a PP about seperating out each individual and asking them without other family members present. Also, I think with the level of stupid present, a list of “yes or no” questions might be helpful. Maybe even have a written checklist and then compare the ones from all the family members and see which ones actually agree.

  5. My first thought was to kick everyone out and ask the patient…then what RuthieH suggests, and the computer guy.
    This works especially well with teens (and my Grampa, who is 98) even though the parents hate leaving, I assure them it will be okay. Sometimes adults and the caregiver to the elderly one think they’ve got it down pat, and all the patient wants it to be heard. Everyone gets a chance, just one at a time.

  6. I’m a librarian. When I’m trying to get information from a customer who is asking for help in a very confusing way I sometimes respond with “tell me the story.” That generally gives me the background information to understand what they are asking for. I have no idea if that question would have helped your particular situation or not.

    • As a pediatrician (akin to a veterinarian) the family’s anxiety is, well, palpable. Extricate the well-intended folks whose expectations are unrealistic and focus the care-givers (problem-owners) with open-opened questions.

  7. I revert to a thorough review of systems. Yes, I ask pretty much every question. I try to steer them to Yes or No answers. Anything comes up “Yes” I try to figure out if it’s “new” (ie in the last week or two).

    For patients that have a mostly positive ROS, I order a basic set of labs plus whatever my gut suggests based on what I think is most likely wrong … and I hope like heck we have old labs to compare to.

    If I don’t find anything grossly abnormal, I discharge them from the ED and refer them to their PCP. If they don’t have a PCP, I give them phone numbers for several in the community.

    As an ED doc, I try to rule out the really bad things, and if I can do that, I feel safe letting the go. This doesn’t do much for my patient satisfaction scores …

  8. Try this:

    How long has Grandpa “not seemed right”? Since Tuesday? Ok…so up until Tuesday, what was atypical day like for him? And what is different now?

  9. I’m an EM resident, and things can get very hairy especially when on other services/admitting 15 people in one night on house staff coverage. Sometimes when I’m not getting anywhere I switch directions and ask about surgical history or med list. that can sometimes re-direct. otherwise separating the family or asking the patient directly can weed through. And sometimes you take a break and come back!

    side note, love the blog!!!

  10. Checklist questions
    What doesn’t “look right” – eyes, hands, etc.?
    Swollen? Discolored? Tremors? Balance?
    Change in eating, weight, hearing, etc.?
    Compare to servicing a vehicle
    Is it a starting, steering, stopping, etc. problem?

  11. If i were this patient’s nurse, I would focus on the patient, and suggest proceding based on any known PMH, current meds, and patient assessment; my goal is acquiring needed info for the doc/team. I would be nice and courteous to the family members. I have found that the quickest way to allay anxieties/fears/frustrations, is to be attentive as possible to their needs (expressed and perceived). That includes letting them know my whereabouts. I would keep them informed on the plan of care and ask for their patience, their help. Along the way, I establish the rules as to how things work, why it’s important for the doc to have all the info he can get. When the family feels that they matter, they’re usually more compliant. Docs don’t usually have as much bed-side time w/ patients/families as I (the nurse) do… that’s why providers who are true teams get the best outcomes in my opinion.

  12. ID caregiver or longest known associate(check)
    Express belief in their diagnostic skill (check)
    Ask what was the one thing/final straw that made you pack grampa up and bring him in right now but not last week?

  13. Every time I call some business, I hear the message “this call may be recorded for quality purposes.”

    Perhaps your interviews with the patient and family should be recorded. It can then be analyzed later for quality purposes. Perhaps your questions were not open-ended enough. Perhaps the family was too vague or could not articulate the problem. A post-review of the conversation may cause qualitative changes that help in future interviews.

    If you were to simply discharge them by saying “I couldn’t figure out what was wrong, because they couldn’t describe things to me properly”, what recourse does the family have? Can you simply take some vitals (BP,etc) as a starting point?

    My two cents.

  14. I had one yesterday, where the patient was in because of allergies, and the family came in too, because each and every one of them had some theory they got from dr google about why the patient could be coughing, other than the patient’s admitting complaint of cough and congestion from allergies. Some of them were pretty outlandish. One family member asked if we were planning to order an MRI of the patient’s neck to rule out something or other he couldn’t pronounce. Others wanted bloodwork, and genetic testing. My approach was to shoot them out, and talk with my patient.

  15. I agree with kicking everyone but the patient out of the room first, and then try the history again. If that doesn’t work then enough of a review of systems to find the most worrisome life threatening problems, “red flags” such as trouble breathing, MI, stroke. And then, as my old chief used to say: “If all else fails, examine your patient.”

  16. I think Min’s suggestion is helpful. In my experience, for patients with vague symptoms, the “why come sit here for hours waiting to see me in the ER instead of going to your doctor tomorrow?” question often yields fruitful information (either a symptom that points to an actual diagnosis, or clear evidence that caregiver fatigue is actually the presenting problem, which I suspect might be the case here.) Also, CBC… Because “grampa doesn’t look right” has turned out to be a GI bleed with significant anemia more than once… Or worsening dementia, and they’re not comfortable saying that.

    • Ah, you point to another possibility. Maybe the family isn’t comfortable saying what is wrong with Grandpa in front of Grandpa. Maybe step out with them and ask them the “Why today, why not last week?” question.

      I love crowdsourcing.

  17. Standing there listening to the various family members chime in about when the patient’s symptoms began (“he started with this on Sunday..” “no, it was Thursday. I remember that because I had to take Jinx to the vet”)

    After a few minutes of this, I usually give up and ask for a urine sample and cross my fingers. Can’t tell you how many times “not feeling right” is a UTI.

  18. If the daughter said “He doesn’t just look right.” I suppose you could have said “Well, does he look left?” Just kidding. On a more serious note, if you weren’t getting anywhere, maybe a “Let’s take a closer look” and do a quick once over. Maybe you wouldn’t have found anything but the family would have been placated enough to give more helpful info.

  19. These are tough situations. Ultimately, they want him to be “checked” and perhaps admitted. Order the standard geriatric battery of tests and hope you find a reason to admit. Send SW in to try to sort out the issues and lend a listening ear while you try to run the rest of the ER.

    When I’m the recipient of the family ganging up on me, there’s almost no way for them to leave happy. Figure out who the alpha dog in the family is and try to interact only with the person. Then the family alpha can deal with the rest of the family in their normal heirarchy.

  20. All the practical suggestions on separating people and asking open-ended questions are good. I’ll add a “tone” suggestion as well: often older people have trouble thinking or moving or speaking quickly, and they get a little paralyzed in the presence of someone who expects them to. I saw this a lot with my parents; they both had calm PCPs they felt they could talk to. But if we had to go to an ED and see a busy, hard-charging, perhaps slightly impatient emergency physician, both of my parents became tongue-tied. Pressure made them inarticulate. This may be a situation where the MD could profit from a few acting lessons. You might get answers faster if you could convey to the patient that there’s no hurry, you have all night.

    • Or you may have a patient try to take all night with you because you’ve made it seem appropriate. Older people, in my experience, like to take far too long to get to the point. There’s time for leisurely interviews (i.e. non-emergent locations like a PCP). And there’s time to be quick (an emergency room).

      • I’m a PCP, but I don’t have the time for “leisurely interviews” either. I agree that the art is to make it seem like you’re not rushing them while trying to get to the point (unfortunately, I’m still trying to master that).

  21. A veterinarian chiming in here: I also go for a basic coughing/sneezing/vomiting/diarrhea/increased thirst/increased urination question when I get dogs/cats in who are ADR (ain’t doing right). I’ll ask about any medication/toxin exposure. It’s scary how many people say they are not giving medications to their pet but then say yes, I gave my dog Aleve when I start rattling off the names of common NSAIDs. In that same vein, sometimes rephrasing questions gets more information for me.

    Then I do a very thorough PE. A lot of small ADR dogs actually have back pain or full anal glands. I think in human medicine social norms prevent you from doing as thorough exams as veterinarians do routinely. My patients get all peripheral lymph nodes checked, mouths opened and gums pressed, bellies palpated, tails lifted to assess the anus and penis/vulva, testicles palpated, mammary glands checked, and many get rectal exams. Because dogs don’t have “privates” I don’t need special permission/chaperones to do my job quickly– just need a good holder so i can open the mouth and touch the feet and not get bitten. Also, because my patients can’t talk and their caregivers aren’t always observant or truthful, the physical is key.
    I think it also helps that if my patients are wearing vests/dresses/t-shirts or whatnot, no one looks askance at me if I unceremoniously unsnap the outfit and set it aside while I do my exam. 🙂

  22. I live in the Upper Midwest now, but I am from down South. I have what is called a “mama ain’t actin’ right” work up which I teach to students. It consists of a CBC, UA, CMP, TSH ,EKG and a CXR. Sometimes I will add a CT if any stroke symptoms seem present. In these instances I have found anemia, Low sodium , cholecystitis, pneumonia, lung cancer, new onset afib or sick sinus , hypothyroidism . I know it seems shotgun, but usually one of these things are abnormal when the history is vague and family reports a change .

    • Haha. I work in the South too, but I call it my “MeeMaw ain’t actin’ right” work up. Or “PawPaw ain’t actin’ right”. The only thing I would add to yours is a Troponin. Throw a battery of tests at an old person, and on the rare occasion that everything is normal, at least the family is satisfied that you’ve tried your best…

  23. I am not credentialed in any field, except that I have a degree in management (a BS in BS).

    I don’t know how many people you have available, but ideally, you should send each of the “others” out of the room with instructions to the nurse(s), student(s), other doc(s), to interview each and record both what was said and what can be inferred.

    Then you should give the patient your undivided attention, engaging the patient in questions and listening while you go through the EMT drill–heart sounds, blood pressure, lung sounds, chest and back thumpings, ankle inspections, differential eye dilatations, glucose levels, what ever you can think of to look like you trying to get to the heart of the problem.

    Review the reports from the other interviews.

    If a path emerges, follow it. If not send them home with instructions to call in if something seems wrong.

  24. I don’t think you did anything wrong. Caregiver fatigue seems likely.
    When faced with the “I’m sick, I’m here for you to figure it out” complaint, I do tend to do what you did, which is narrow my broad “what can I help you with today” question to specific complaints such as pain, nausea, vomiting, weakness, dizziness, confusion. If that doesn’t get me anywhere, I do a gomergram (credit House of God) and hope for the best.
    Daylight hours on weekdays, the social worker can be a big help, especially if I don’t have anything that meets admission criteria.

    As far as being accused of being “Difficult” for asking specific questions- some people just want to be unpleasant. It’s how they feel like they’re accomplishing something.

  25. As a patient with an undiagnosed rheumatic condition (we assume) I have discovered that the human body can do some really odd/unexplainable things and produce symptoms that are very vague and very difficult to describe let alone diagnose. How do you describe something you’ve never experienced before and is unlike anything you have experienced? There is literally nothing to compare it to for description purposes. I can relate to the “not feeling right” and “not looking right” patient, it’s a very frustrating spot to be in.

    It’s gotten to the point where I will now only go to the doc if I am experiencing a very apparent symptom, something that is visible, like swollen fingers or rash. I will not go anymore when my “not feeling right” is at it’s strongest it’s a waste of my and the docs time. I blame no-one for that. It’s certainly not my fault and most definitely not the docs fault that I can’t “show” her something/give her a solid clue.

    So in a nutshell I think sometimes there is something wrong but as far as medical care goes if the body isn’t giving clear/direct clues it’s very difficult for the doc to know what direction to go as far as care goes. The body just isn’t giving up it’s secret yet and that’s all there is to it.

  26. In these situations, I often say, “OK, well what happened today that prompted you to come to the emergency department?” Sometimes that will give me one thing to initially focus on.

    I had a patient last week, and her husband was doing all of the talking, and started with “Well, it all started in 1995…” I had to cut him off to get them to tell me what had been happening in the past few days, but I tried to placate him by letting him know that I would get to the history in a few minutes. That seemed to allow them to focus on the chief complaint and not the entire medical history.

  27. When I find I’m getting resistance to questions, I try to explain why I want to know the answer to a specific question, and try to give them a reason to why they may want to provide it voluntarily. In this case,

    “Not looking right” is hard for a doctor to diagnosis, and in elderly patients, it can sometimes be something very serious (letting them know I share their concerns) Without knowing more specifics about what is wrong, what exactly is not right, I may have to order lots of tests, which might end up costing grandpa a lot of unnecessary costs, even if he has insurance, and I don’t want to do that, and I’m sure you don’t either. If you could give me more specific details about what exactly you’ve noticed, we can avoid some of these tests and hone in on just the necessary ones, the ones that will tell us what’s going on, and find what out what’s wrong with grandpa.

  28. I’m not sure I understand what the problem is…this patient, being elderly is going to get the 10,000 dollar workup either way. Labs, UA, CT head, CXR, blah blah and in the end they will be admitted.

  29. There’s a difference between can’t give you more information and won’t give you more information.

    If they really can’t tell you, you observe the pt. You either find something that can be treated and treat it or you tell the family “we can’t make him any better, this is his new baseline, I’m sorry.”

    If they simply won’t give you any more information, you tell them “unless I can get more information I’m going to have to pursue some very painful, very dangerous tests (LP, angiogram, biposy, whatever applies to the pt’s case). I really don’t want to harm your relative to hurt them. Can you please give me some more information so I don’t have to make him feel even worse.”

  30. This is so very common and frustrating.
    1. Treating social problems in a medical setting is a losing game even in a psychiatriac setting. the overlay of social dysfunction is profound in this tale.

    2. When I find myself trapped in this setting which is, sadly increasing, I begin by responding to the vague complaints or descriptions of symptoms “in what way….”. when the patient or other “responsible” party continues to try to push the responsibility for their part in the interview on to me, see #1.

  31. I see this all the time. The family can’t answer the questions because they are not with their loved one very much. Also, there is the problem of low functioning IQ with a poor vocabulary. Many people lack the speech skills to describe what they see.

    Good lead questions:
    What are you concerned about today?
    Who knows the patient best?
    Have you noticed…blah, blah, blah.
    How is your loved one sleeping, eating, drinking, pooping, etc…blah, blah, blah.

    Recognize early that admission is probable and plan accordingly. Although Medicare does not admit it, many admissions with the elderly are for social reasons, not sound medical reasons.

  32. I m an ER physician and have had many such encounters. Recently a VA nurse practitioner brought her mother in with similar symptoms. I work these cases of the elderly as I would the babies. Babies can’t tell you what’s wrong and parents just sat there’s something wrong. They’re not acting right. I go through my ROS and do the full cardiac work up. If there’s a major abnormality in the labs/X-rays I admit and let the PCP sort it out. The PCPs have better repore with the patient/family than the ER doc. You’re right the family just wants their loved one admitted. Whether there’s truly something wrong or just guilt for not being there for their loved one in the past. My primary concern as an ER physician is first to save lives. Then I need to make the family happy and prevent writeups that I have to answer to, which wastes my time. I see my job as customer service. These people want to be made happy. If you ask too many questions they get angry. They get angry if you make it seem like they’re not taking care of their loved one. So I only ask what they perceive the problem to be, the ROS, and do labs. I then put it in the PCPs lap. That way I spend less time in the room arguing with family and everyone is happy. If the family wants the pt. admitted and they perceive you don’t they’ll get angry with you and not the PCP.

  33. I think you asked too many questions. When it became clear that Grampa “doesn’t look right” and you sense hostility, it behooves you to go to plan B. You say, “Let’s do Grampa’s physical exam,” and do that. That probably will show a frail elderly person with no obvious cause for his visit. You say, “We are going to carefully test Grampa to see what’s wrong.” Then you order your weakness workup. Mine is a CBC, chem profile, urinalysis, EKG and chest x-ray. It can be added to, depending on what your exam suggested, perhaps with cardiac enzymes, or D-dimer, or TSH, or head CT–whatever. Order it all as a package, not piecemeal. You say, “This will take about two hours (or however long it might take) to accomplish, because testing takes time.” Then you can leave the room, cool off, check to see if he has old records (can be extraordinarily helpful at times), and determine if he has a primary care physician to whom he can be admitted. The family is left with the notion that something is happening, so they may (or may not) be mollified. Then you can see several more patients, and come back to this one when all the tests are done. You then tell the family what the tests showed. I find it helpful to print the results and hand them to the most annoying family member. Then they can’t tell the hospital CEO that “He didn’t do nothing.” After all, a workup was done and the results were presented to the patient and his family. Then I call the PCP or hospitalist to admit the patient, because your workup will probably have revealed a reason to admit Grampa. The key is to not get embroiled in the family’s distress, but rather to have a plan to evaluate the patient and get him admitted.

  34. I am no longer an EP. I now am a FP. I did that gig for 13 years and finally said ,”ENOUGH” This family you described of which I have seen my share were complete idiots and was one of the big reasons I left EM. We live in a world now were idiots are no longer considered idiots they are considered “socially disadvanteged” and whatever “rabbit hole” they are jumping down, all responsible parties are supposed to jump down the rabbit hole with them. Because if you don’t your not compassionate, or your not communicating or your not whatever. But just remember when you go down the hole with them your just another PC asskissing whore that basically gives the paying customer whatever they want. By definition that’s a whore. When you stop being rational and become irrational to make some idiot happy with your care what else can you call yourself. In family medicine I deal with some of that but when it gets to the level that crosses the magic line from just stupid to complete idiot , I send them packing. Why you ask? Because I can, it is my show and my rules because I own the bussiness. I practice medicine the best I know how and try to stay in the real world and make decisions with real facts as clearly as I can get at them. My practice is full. I feel bad for you guys and gals because you are in a tough positions in EM. It is a thankless job. I do miss occasionally participating in a miracle but the sacrafice is worth it. God’s Speed Friends. Your Friend Dr G.

  35. We all get these difficult families from time to time. ist thing is to have a policy of not allowing more than 2 family members at a time into the exam room. Try to joke a little with the patient and/or family members…a little humor goes a long way to get them to relax. Ask the patient if he is a veteran. Most enjoy the recognition and those who are will appreciate being recognized as such. The rest is to use your experience to ferret out as much info as possible, then a thorough PE and approriate studies. Can’t please everyone, though, and personally, I don’t give a rat’s ass about PG scores

  36. Charles J. Neilson MD on

    Telling the family that the HISTORY is the most important aspect in getting the diagnosis seems to give one a few more questions before these idiot families go bonkers again. They will hold a grudge because you asked “too many questions” anyway. Their answers are typically like this example… “it’s been going on for a while”……when asked what the diagnosis was in the recent evaluation elsewhere…..”don’t know”. You know you have really people really interested in the welfare of the patient when they make themselves the center of attention and then want to leave with the patient. I believe asking everyone to leave the room but the patient or one parent if a child is a good recommendation.

  37. When the family says “he just doesn’t look right” (JDLR), it means they’ve made the best evaluation they can without any medical training. “JDLR” is a valid observation, but without the skills to expand on it they’re frustrated by their inability to vocalize what they think is wrong.

    It’s time to do labs, an ECG and an eval for the “dwindles”. Does he have a primary? Does medical records have a Hx? You’re not done yet!

  38. We all have had these encounters.

    When the patient and/or family are vague, I ask, “what would you like me to do for you?”. If they persist in being vague, I realize that pressing them for more information will only aggravate them. At this point I document the lack of history, do a detailed physical examination, and order a basic work up (usually CBC, CMP, UA, TSH; but tailored to the situation). I avoid expensive work ups. Remember the radiologist has to have a complaint that supports the CXR or CT you ordered. “Mama doesn’t look right” doesn’t cut it. Calling it “weakness” when the patient and/or family never verbalized or demonstrated weakness is dishonest (yes, even fraud). Pressing most vague patients/families for more information is like extracting a worthless ROS from a drunk just so you can bill at a certain level. Document that the ROS is unobtainable and move on.

    If I find something on the physical examination or basic work up that justifies admission, then I admit the patient. If I find nothing that justifies admission, then I explain to the patient and/or family that the criteria for admission to the hospital have not been met and I then discharge them to home to follow up with their primary care physician.

    Vagueness often indicates an unspoken motive that the patient and/or family don’t even recognize. With the elderly it is usually caregiver fatigue and they want the patient admitted. I am concerned about how many respond to just admit the patient and let the hospitalist/PCP figure it out. They came to see me for me to figure it out. In my hospital I have to meet Interqual criteria for admission. Admitting the patient when they have not met criteria for admission takes more of my time, reduces patient satisfaction scores when they are discharged without the “problem” being solved, and sets the patient and/or family up for this to happen over and over again. Do the right thing for the right reasons (while protecting yourself and your hospital at the same time).

  39. Sorry, I’ve got other patients, and so do you, Doc. Most of them actually sick.
    The first thing I do is enforce the 1 visitor policy at my facility. I let them rock/paper/scissors that decision, then go from there.
    If, after 2 minutes, the one left can’t articulate a 15 words or less reason-for-visit, I send them outside until they can collectively come up with one. I encourage them to try a shout out on their cellphones to someone with a clue.
    And yes, Press Ganey be damned, I have suggested to them out loud that if necessary they contact the Psychic Friends Hotline, because the waiting room is usually 20 deep, and we need the bed. I have explained to them that if they don’t know why they’re here, neither do we. In the meantime, I go back to other patients.

    And if a 12 lead, urine dip, CBC and Chem 7 along with vital signs come back normal, they’ll be taking gramps out the door the same way they came in, about an hour later.

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