What is the first line of Moby-Dick? “Call me Ishmael.”
This question came up during a round of trivia. I play weekly at a local restaurant with a consistent team and a set table. Trivia requires the regurgitation of random knowledge acquired from books, television, or life experiences. When I know an answer, I feel an immense sense of satisfaction. The practice of medicine or perhaps, more aptly, one’s time in medical school, can sometimes feel like a long trivia round. Characteristic findings lead to stereotyped answers. If urine has muddy brown casts, I answer acute tubular necrosis and call the renal team.
What is the gene involved in cystic fibrosis? “CFTR.”
She was 15 years old and had spent more time in the hospital than I had. Her disease was a central part of her life. I sat in her room one afternoon, and we talked about college and her thoughts on the future. I asked her if she had undergone genetic testing to see if her mutation was known; she said no, she did not want to know. She was happy. She accepted her disease and its impact on her life, but she did not want to know her mutation and she did not want to meet other teenagers with cystic fibrosis. She knew her challenges, but she was afraid that she may pass on her disease if she joined a support group, met a boy, fell in love, and started a family. She was 15 and struggling with questions beyond her age. Her disease had an answer in a trivia round, but that question could not begin to capture what she was going through.
What drug is given at the start of a cardiac arrest? “Epinephrine.”
He was in his 50s, with hepatocellular carcinoma, jaundice, and gross ascites. His cancer had metastasized, he was not a candidate for transplant, and his creatinine was doubling daily, indicating hepatorenal syndrome and giving him a prognosis of weeks. When I performed an abdominal paracentesis, he was relieved because he was one step closer to returning home. When I asked what his hope for the hospitalization was, he said he wanted to be less yellow so he could return to work. He never mentioned dying, and it was unclear what his previous physicians had told him. If he went into cardiac arrest, the algorithm I had learned, taught, and performed, like the answer to the trivia question, was clear. But for him, he had a terminal disease with a poor prognosis. The question did not ask what he wanted or what we should do for him.
Trivia questions can assess knowledge, and they have concrete answers. Answering trivia questions can be fun, and winning makes the time spent sweeter. In medicine, a lab test or imaging study can give a clear diagnosis and a concrete answer. However, the answers to open-ended questions often matter more than those to the concrete ones do. What are you worried about? What are your goals? What is important to you? I now ask my new patients these questions in addition to the standard medical and family history ones. These questions pry open the encounter and allow me to treat the person and the family, not just the disease. Knowing a patient’s fear is a cancer diagnosis makes me approach a visit for a cough differently than I would a visit derailed by a cold. Here, medicine surpasses the lab values, imaging studies, and medications and becomes an intensely interpersonal endeavor. For concrete answers, I’ll keep playing trivia.
Siddhartha A. Dante, MD
S.A. Dante is a fourth-year resident in internal medicine and pediatrics, University of Chicago Medicine and Comer Children’s Hospital, Chicago, Illinois; e-mail: email@example.com.