confused-full"That doesn't make any sense." The patient sits across the exam room and looks at me with a combination of surprise and hurt.  He had answered all of my questions to the best of his abilities, hoping that I would figure out what was causing the symptoms and fix his problem.  A bit of doubt shows on his brow as he goes over what he feels and what happened in the past.  Did he say things wrong?  Did he mistake the way it felt?  Is he just bad at explaining things?

"I am not accusing you of being untruthful.  Your symptoms are your symptoms, and you felt what you felt.  Unfortunately they don't always read the medical textbooks and so make me earn my keep.  I believe your symptoms are real; I just don't understand how they fit together.  It's confusing." I say this as reassuringly as possible.  He relaxes visibly as I speak.

But that doesn't change the fact that the symptoms defy logic.  It's my job to figure things out and fix things, right?  Isn't this an admission of defeat?  Isn't it a confession of my inadequacy?  Won't this undermine the thing that I have said is the cornerstone of a doctor/patient relationship: trust?

Some people seem impatient for an answer, but most are OK with me not knowing for a while.  The thing that makes it acceptable for me to be confused is the longstanding nature of the relationship of a patient with their PCP.  This is one page in the book, not the whole story.  This concept - of the patient's "story" - is one I actually use in this situation.  I say:

You know when you see a movie that is really confusing in the start?  You don't know who is who, or why one person was mad at the other, etc.  It is just hard to figure out what is going on.  But later on in the movie things become clear.  You say "Oh, so that's who that guy was!  That's why she was so mad at him."  It all clears up over time.  With your illness, we may just be at that confusion part of the movie.  It may just take time for us to be able to make sense of what is going on.

confusedI have to say that I actually am glad for those cases where things are confusing at the start.  No, I am not happy for the patients, but the hard stuff is what separates the good docs from the bad ones.  If I can sort through things and come up with an answer when one wasn't apparent, I am showing the merit of all of my hard work.  I justify my salary.  I go home feeling like I am more than just a bunch of algorythms.

I don't want everyone to be confusing, but just because things seem to not add up it doesn't mean we won't come to a good answer eventually.

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